艰难梭菌医院感染及预防控制研究进展
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摘要
艰难梭菌是引起医源性肠道感染的重要致病菌,临床表现为腹痛、腹泻、肠炎等,严重者可并发低血压、休克及腹腔感染,且存在复发性感染的风险,对患者的生活质量造成显著的负面影响。随着抗菌药物的广泛使用,艰难梭菌感染的发病率逐年上升,复发及死亡人数也随之上升,其感染的预防控制需要引起足够的重视。本研究综述艰难梭菌感染的流行病学、危险因素、诊断及治疗,并探讨其预防控制策略,为进一步预防控制提供参考借鉴。
Clostridium difficile is a major species of pathogen causing iatrogenic intestinal infection which clinically characterized by abdominal pain,diarrhea and enteritis,and severe cases may be complicated with low blood pressure,shock and abdominal cavity infection and are at the risk of recurrent infection,which has negative impact on the quality of life of the patients.The incidence of C.difficile infection is increased year by year with the broad use of antibiotics,and the number of cases of recurrent infection and death was also increased,therefore,the prevention and control of the infection needs to be attached great importance.The review gives presentation about the epidemiological characteristics,risk factors,diagnosis and treatment of the C.difficile infection and explores the prevention and control strategies so as to provide guidance for prevention and control of the infection.
Clostridium difficile is a major species of pathogen causing iatrogenic intestinal infection which clinically characterized by abdominal pain,diarrhea and enteritis,and severe cases may be complicated with low blood pressure,shock and abdominal cavity infection and are at the risk of recurrent infection,which has negative impact on the quality of life of the patients.The incidence of C.difficile infection is increased year by year with the broad use of antibiotics,and the number of cases of recurrent infection and death was also increased,therefore,the prevention and control of the infection needs to be attached great importance.The review gives presentation about the epidemiological characteristics,risk factors,diagnosis and treatment of the C.difficile infection and explores the prevention and control strategies so as to provide guidance for prevention and control of the infection.
引文
[1]居阳,李燕明.艰难梭菌感染预防与控制进展[J].中国临床医生杂志,2016,44(4):21-25.
[2]Moudgal V,Sobel JD.Clostridium difficile colitis:a review[J].Hosp Pract,2012,40(1):139-148.
[3]Kundrapu S,Sunkesula VC,Jury LA,et al.Utility of perirectal swab specimens for diagnosis of Clostridium difficile infection[J].Clin Infect Dis,2012,55(11):1527-1530.
[4]Rodriguez C,Van BJ,Taminiau B,et al.Clostridium difficile infection:early history,diagnosis and molecular strain typing methods[J].Microb Pathog,2016,97:59-78.
[5]International C.Antibiotic resistance threats in the United States,2013[M].2013:1-22.
[6]Magill SS,Edwards JR,Bamberg W,et al.Multistate pointprevalence survey of health care-associated infections[J].NEngl J Med,2014,370(13):1198-1208.
[7]Nearly half a million Americans suffered from Clostridium difficile infections in a single year[OL].https://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html.
[8]Levy AR,Szabo SM,Lozanoortega G,et al.Incidence and costs of Clostridium difficile infections in Canada[J].Open Forum Infect Dis,2015,2(3):ofv076.
[9]Wiuff C,Banks AL,Fitzpatrick F,et al.The need for European surveillance of CDI[J].Adv Exp Med Biol,2018,1050:13-25.
[10]Choi HY,Park SY,Kim YA,et al.The epidemiology and economic burden of Clostridium difficile infection in Korea[J].Biomed Res Int,2015,2015(3):510386.
[11]王浦.华南地区艰难梭菌流行病学研究与新型分子生物学检测技术评估[D].南方医科大学,2014.
[12]高燕婷,章黎华,王粟,等.住院腹泻患者艰难梭菌感染的临床特点分析[J].上海交通大学学报(医学版),2014,34(10):1481-1484,1496.
[13]刘元元,刘文恩,简子娟,等.住院腹泻患者艰难梭菌检测与分析[J].中国感染控制杂志,2012,11(4):293-296.
[14]唐升宏.重症监护病房AAD调查与艰难梭菌病原检测[D].中南大学,2013.
[15]金慧,吴建浓,韦凌娅,等.艰难梭菌分离培养与病原学分子特征研究[J].预防医学,2014,26(6):602-603.
[16]高姗,金慧,李福琴,等.艰难梭菌在高风险科室医院感染流行趋势研究[J].中华医院感染学杂志,2015,25(11):2423-2425.
[17]Loo VG,Bourgault AM,Poirier L,et al.Host and pathogen factors for Clostridium difficile infection and colonization[J].N Engl J Med,2011,365(18):1693-1703.
[18]Cohen J,Limbago B,Dumyati G,et al.Impact of changes in Clostridium difficile testing practices on stool rejection policies and C.difficile positivity rates across multiple laboratories in the United States[J].J Clin Microbiol,2014(52):632-634.
[19]Planche TD,Davies KA,Coen PG,et al.Differences in outcome according to Clostridium difficile testing method:a prospective multicenter diagnostic validation study of C.difficile infection[J].Lancet Infect Dis,2013,13(11):936-945.
[20]Ticinesi A,Nouvenne A,Folesani G,et al.Multimorbidity in elderly hospitalised patients and risk of Clostridium difficile infection:a retrospective study with the Cumulative Illness Rating Scale(CIRS)[J].Bmj Open,2015,5(10):e009316.
[21]Kuntz JL,Johnson ES,Raebel MA,et al.Clostridium difficile infection,Colorado and the Northwestern United States,2007[J].Emerg Infect Dis,2012,18(6):960-962.
[22]Ziakas PD,Joyce N,Zacharioudakis IM,et al.Prevalence and impact of Clostridium difficile infection in elderly residents of long-term care facilities,2011:a nationwide study[J].Medicine,2016,95(31):e4187.
[23]Hensgens MPM,Goorhuis A,Dekkers OM,et al.Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics[J].Anesthesiology,2006,105(5):898-901.
[24]Leffler DA,Lamont JT.Clostridium difficile infection-NEJM[J].Clin Med,2015,8(5):544-547.
[25]Pakyz AL,Jawahar R,Wang Q,et al.Medication risk factors associated with healthcare-associated Clostridium difficile infection:a multilevel model case-control study among 64 USacademic medical centres[J].J Antimicrob Chemother,2014,69(4):1127-1131.
[26]Dubberke ER,Carling P,Carrico R,et al.Strategies to prevent Clostridium difficile infections in acute care hospitals:2014update[J].Infect Control Hosp Epidemiol,2014,35(Suppl 2):628-645.
[27]程敬伟,刘文恩,马小军,等.中国成人艰难梭菌感染诊断和治疗专家共识[J].协和医学杂志,2017,8(2):131-138.
[28]Mullane KM,Miller MA,Weiss K,et al.Efficacy of fidaxomicin versus vancomycin as therapy for Clostridium difficile infection in individuals taking concomitant antibiotics for other concurrent infections[J].Clin Infect Dis,2011,53(5):440-447.
[29]Siegfried J,Dubrovskaya Y,Flagiello T,et al.Initial therapy for mild to moderate Clostridium difficileinfection:exploring the role of oral metronidazole versus vancomycin in 168hospitalized patients[J].Infect Dis Clin Pract,2016,24(4):1-4.
[30]Nelson RE,Schwabdaugherty EM,et al.Comparative effectiveness of vancomycin and metronidazole for the prevention of recurrence and death in patients with Clostridium difficile infection[J].JAMA Intern Med,2017,177(4):546-553.
[31]Feher C,Munez RE,Merino AP,et al.The efficacy of fidaxomicin in the treatment of Clostridium difficile infection in a real-world clinical setting:a Spanish multi-centre retrospective cohort[J].Eur J Clin Microbiol Infect Dis,2016,36(2):295-303.
[32]Cornely OA,Crook DW,Esposito R,et al.Fidaxomicin versus vancomycin for infection with Clostridium difficile in Europe,Canada,and the USA:a double-blind,non-inferiority,randomised controlled trial[J].Lancet Infect Dis,2012,12(4):281-289.
[33]Rivkin A,Gim S.Rifaximin:new therapeutic indication and future directions[J].Clin Ther,2011,33(7):812-827.
[34]van Nood E,Vrieze A,Nieuwdorp M,et al.Duodenal infusion of donor feces for recurrent Clostridium difficile[J].N Engl JMed,2013,368(5):407-415.
[35]Rubin TA,Gessert CE,Aas J,et al.Fecal microbiome transplantation for recurrent Clostridium difficile infection:report on a case series[J].Anaerobe,2013,19(2):22-26.
[36]Pattani R,Palda VA,Hwang SW,et al.Probiotics for the prevention of antibiotic-associated diarrhea and Clostridium difficile infection among hospitalized patients:systematic review and meta-analysis[J].Open Med,2013,7(2):e56-e67.
[37]Shen NT,Maw A,Tmanova LL,et al.Timely use of probiotics in hospitalized adults prevents Clostridium difficile infection:a systematic review with meta-regression analysis[J].Gastroenterology,2017,152(8):1889-1900.
[38]Shah PJ,Vakil N,Kabakov A.Role of intravenous immune globulin in streptococcal toxic shock syndrome and Clostridium difficile infection[J].Am J Health Syst Pharm,2015,72(12):1013-1019.
[39]Surawicz CM,Brandt LJ,Binion DG,et al.Guidelines for diagnosis,treatment,and prevention of Clostridium difficile infections[J].Am J Gastroenterol,2013,108(4):478-498.
[40]Scott R,James McCormick,Genevieve B,et al.Practice parameters for the management of Clostridium difficile infection[J].Dis Colon Rectum 2015,58(1):10-24.
[41]McDonald LC,Gerding DN,Johnson S,et al.Clinical practice guidelines for Clostridium difficile infection in adults and children:2017update by the Infectious Diseases Society of A-merica(IDSA)and Society for Healthcare Epidemiology of A-merica(SHEA)[J].Clin Infect Dis,2018,66(7):987-994.
[42]Mermel LA,Jefferson J,Blanchard K,et al.Reducing Clostridium difficile incidence,colectomies,and mortality in the hospital setting:a successful multidisciplinary approach[J].Jt Comm J Qual Patient Saf,2013,39(7):298-305.
[43]王晓辉,宗志勇.艰难梭菌感染现状与预防措施[J].中华临床感染病杂志,2016,9(3):213-223.
[44]Centers for Disease Control and Prevention.Multidrug-resistant organism and Clostridium difficile infection module.2016[OL].http://www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf.Accessed 9March 2016.
[45]Kundrapu S,Sunkesula VC,Jury L A,et al.Utility of perirectal swab specimens for diagnosis of Clostridium difficile infection[J].Clin Infect Dis,2012,55(11):1527-1530.
[46]Bobulsky GS,Al-Nassir WN,Riggs MM,et al.Clostridium difficile skin contamination in patients with C.difficile-associated disease[J].Clin Infect Dis,2008,46(3):447-450.
[47]Oughton MT,Loo VG,Nandini D,et al.Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile[J].Infect Control Hosp Epidemiol,2009,30(10):939-944.
[48]Jabbar U,Leischner J,Kasper D,et al.Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands.[J].Infect Control Hosp Epidemiol,2010,31(6):565-570.
[49]Horn K,Otter JA.Hydrogen peroxide vapor room disinfection and hand hygiene improvements reduce Clostridium difficile infection,methicillin-resistant Staphylococcus aureus,vancomycin-resistant Enterococci,and extended-spectrum-lactamase[J].Am J Infect Control,2015,43(12):1354-1356.
[50]Nagaraja A,Visintainer P,Haas JP,et al.Clostridium difficile infections before and during use of ultraviolet disinfection[J].Am J Infect Control,2015,43(9):940-945.
[51]Eyre DW,Cule ML,Wilson DJ,et al.Diverse sources of C.difficile infection identified on whole-genome sequencing[J].N Engl J Med,2013,369(13):1195-1205.
[52]Grigoras CA,Zervou FN,Zacharioudakis IM,et al.Isolation of C.difficile carriers alone and as part of a bundle approach for the prevention of Clostridium difficile infection(CDI):a mathematical model based on clinical study data[J].PLoSOne,2016,11(6):e0156577.
[53]Malani AN,Richards PG,Kapila S,et al.Clinical and economic outcomes from a community hospital′s antimicrobial stewardship program[J].Am J Infect Control,2013,41(2):145-148.
[54]Richard AM,Raheelah A,Atef SN,et al.A review of quality measures for assessing the impact of antimicrobial stewardship programs in hospitals:[J].Antibiotics,2016,5(1):E5.
[2]Moudgal V,Sobel JD.Clostridium difficile colitis:a review[J].Hosp Pract,2012,40(1):139-148.
[3]Kundrapu S,Sunkesula VC,Jury LA,et al.Utility of perirectal swab specimens for diagnosis of Clostridium difficile infection[J].Clin Infect Dis,2012,55(11):1527-1530.
[4]Rodriguez C,Van BJ,Taminiau B,et al.Clostridium difficile infection:early history,diagnosis and molecular strain typing methods[J].Microb Pathog,2016,97:59-78.
[5]International C.Antibiotic resistance threats in the United States,2013[M].2013:1-22.
[6]Magill SS,Edwards JR,Bamberg W,et al.Multistate pointprevalence survey of health care-associated infections[J].NEngl J Med,2014,370(13):1198-1208.
[7]Nearly half a million Americans suffered from Clostridium difficile infections in a single year[OL].https://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html.
[8]Levy AR,Szabo SM,Lozanoortega G,et al.Incidence and costs of Clostridium difficile infections in Canada[J].Open Forum Infect Dis,2015,2(3):ofv076.
[9]Wiuff C,Banks AL,Fitzpatrick F,et al.The need for European surveillance of CDI[J].Adv Exp Med Biol,2018,1050:13-25.
[10]Choi HY,Park SY,Kim YA,et al.The epidemiology and economic burden of Clostridium difficile infection in Korea[J].Biomed Res Int,2015,2015(3):510386.
[11]王浦.华南地区艰难梭菌流行病学研究与新型分子生物学检测技术评估[D].南方医科大学,2014.
[12]高燕婷,章黎华,王粟,等.住院腹泻患者艰难梭菌感染的临床特点分析[J].上海交通大学学报(医学版),2014,34(10):1481-1484,1496.
[13]刘元元,刘文恩,简子娟,等.住院腹泻患者艰难梭菌检测与分析[J].中国感染控制杂志,2012,11(4):293-296.
[14]唐升宏.重症监护病房AAD调查与艰难梭菌病原检测[D].中南大学,2013.
[15]金慧,吴建浓,韦凌娅,等.艰难梭菌分离培养与病原学分子特征研究[J].预防医学,2014,26(6):602-603.
[16]高姗,金慧,李福琴,等.艰难梭菌在高风险科室医院感染流行趋势研究[J].中华医院感染学杂志,2015,25(11):2423-2425.
[17]Loo VG,Bourgault AM,Poirier L,et al.Host and pathogen factors for Clostridium difficile infection and colonization[J].N Engl J Med,2011,365(18):1693-1703.
[18]Cohen J,Limbago B,Dumyati G,et al.Impact of changes in Clostridium difficile testing practices on stool rejection policies and C.difficile positivity rates across multiple laboratories in the United States[J].J Clin Microbiol,2014(52):632-634.
[19]Planche TD,Davies KA,Coen PG,et al.Differences in outcome according to Clostridium difficile testing method:a prospective multicenter diagnostic validation study of C.difficile infection[J].Lancet Infect Dis,2013,13(11):936-945.
[20]Ticinesi A,Nouvenne A,Folesani G,et al.Multimorbidity in elderly hospitalised patients and risk of Clostridium difficile infection:a retrospective study with the Cumulative Illness Rating Scale(CIRS)[J].Bmj Open,2015,5(10):e009316.
[21]Kuntz JL,Johnson ES,Raebel MA,et al.Clostridium difficile infection,Colorado and the Northwestern United States,2007[J].Emerg Infect Dis,2012,18(6):960-962.
[22]Ziakas PD,Joyce N,Zacharioudakis IM,et al.Prevalence and impact of Clostridium difficile infection in elderly residents of long-term care facilities,2011:a nationwide study[J].Medicine,2016,95(31):e4187.
[23]Hensgens MPM,Goorhuis A,Dekkers OM,et al.Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics[J].Anesthesiology,2006,105(5):898-901.
[24]Leffler DA,Lamont JT.Clostridium difficile infection-NEJM[J].Clin Med,2015,8(5):544-547.
[25]Pakyz AL,Jawahar R,Wang Q,et al.Medication risk factors associated with healthcare-associated Clostridium difficile infection:a multilevel model case-control study among 64 USacademic medical centres[J].J Antimicrob Chemother,2014,69(4):1127-1131.
[26]Dubberke ER,Carling P,Carrico R,et al.Strategies to prevent Clostridium difficile infections in acute care hospitals:2014update[J].Infect Control Hosp Epidemiol,2014,35(Suppl 2):628-645.
[27]程敬伟,刘文恩,马小军,等.中国成人艰难梭菌感染诊断和治疗专家共识[J].协和医学杂志,2017,8(2):131-138.
[28]Mullane KM,Miller MA,Weiss K,et al.Efficacy of fidaxomicin versus vancomycin as therapy for Clostridium difficile infection in individuals taking concomitant antibiotics for other concurrent infections[J].Clin Infect Dis,2011,53(5):440-447.
[29]Siegfried J,Dubrovskaya Y,Flagiello T,et al.Initial therapy for mild to moderate Clostridium difficileinfection:exploring the role of oral metronidazole versus vancomycin in 168hospitalized patients[J].Infect Dis Clin Pract,2016,24(4):1-4.
[30]Nelson RE,Schwabdaugherty EM,et al.Comparative effectiveness of vancomycin and metronidazole for the prevention of recurrence and death in patients with Clostridium difficile infection[J].JAMA Intern Med,2017,177(4):546-553.
[31]Feher C,Munez RE,Merino AP,et al.The efficacy of fidaxomicin in the treatment of Clostridium difficile infection in a real-world clinical setting:a Spanish multi-centre retrospective cohort[J].Eur J Clin Microbiol Infect Dis,2016,36(2):295-303.
[32]Cornely OA,Crook DW,Esposito R,et al.Fidaxomicin versus vancomycin for infection with Clostridium difficile in Europe,Canada,and the USA:a double-blind,non-inferiority,randomised controlled trial[J].Lancet Infect Dis,2012,12(4):281-289.
[33]Rivkin A,Gim S.Rifaximin:new therapeutic indication and future directions[J].Clin Ther,2011,33(7):812-827.
[34]van Nood E,Vrieze A,Nieuwdorp M,et al.Duodenal infusion of donor feces for recurrent Clostridium difficile[J].N Engl JMed,2013,368(5):407-415.
[35]Rubin TA,Gessert CE,Aas J,et al.Fecal microbiome transplantation for recurrent Clostridium difficile infection:report on a case series[J].Anaerobe,2013,19(2):22-26.
[36]Pattani R,Palda VA,Hwang SW,et al.Probiotics for the prevention of antibiotic-associated diarrhea and Clostridium difficile infection among hospitalized patients:systematic review and meta-analysis[J].Open Med,2013,7(2):e56-e67.
[37]Shen NT,Maw A,Tmanova LL,et al.Timely use of probiotics in hospitalized adults prevents Clostridium difficile infection:a systematic review with meta-regression analysis[J].Gastroenterology,2017,152(8):1889-1900.
[38]Shah PJ,Vakil N,Kabakov A.Role of intravenous immune globulin in streptococcal toxic shock syndrome and Clostridium difficile infection[J].Am J Health Syst Pharm,2015,72(12):1013-1019.
[39]Surawicz CM,Brandt LJ,Binion DG,et al.Guidelines for diagnosis,treatment,and prevention of Clostridium difficile infections[J].Am J Gastroenterol,2013,108(4):478-498.
[40]Scott R,James McCormick,Genevieve B,et al.Practice parameters for the management of Clostridium difficile infection[J].Dis Colon Rectum 2015,58(1):10-24.
[41]McDonald LC,Gerding DN,Johnson S,et al.Clinical practice guidelines for Clostridium difficile infection in adults and children:2017update by the Infectious Diseases Society of A-merica(IDSA)and Society for Healthcare Epidemiology of A-merica(SHEA)[J].Clin Infect Dis,2018,66(7):987-994.
[42]Mermel LA,Jefferson J,Blanchard K,et al.Reducing Clostridium difficile incidence,colectomies,and mortality in the hospital setting:a successful multidisciplinary approach[J].Jt Comm J Qual Patient Saf,2013,39(7):298-305.
[43]王晓辉,宗志勇.艰难梭菌感染现状与预防措施[J].中华临床感染病杂志,2016,9(3):213-223.
[44]Centers for Disease Control and Prevention.Multidrug-resistant organism and Clostridium difficile infection module.2016[OL].http://www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf.Accessed 9March 2016.
[45]Kundrapu S,Sunkesula VC,Jury L A,et al.Utility of perirectal swab specimens for diagnosis of Clostridium difficile infection[J].Clin Infect Dis,2012,55(11):1527-1530.
[46]Bobulsky GS,Al-Nassir WN,Riggs MM,et al.Clostridium difficile skin contamination in patients with C.difficile-associated disease[J].Clin Infect Dis,2008,46(3):447-450.
[47]Oughton MT,Loo VG,Nandini D,et al.Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile[J].Infect Control Hosp Epidemiol,2009,30(10):939-944.
[48]Jabbar U,Leischner J,Kasper D,et al.Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands.[J].Infect Control Hosp Epidemiol,2010,31(6):565-570.
[49]Horn K,Otter JA.Hydrogen peroxide vapor room disinfection and hand hygiene improvements reduce Clostridium difficile infection,methicillin-resistant Staphylococcus aureus,vancomycin-resistant Enterococci,and extended-spectrum-lactamase[J].Am J Infect Control,2015,43(12):1354-1356.
[50]Nagaraja A,Visintainer P,Haas JP,et al.Clostridium difficile infections before and during use of ultraviolet disinfection[J].Am J Infect Control,2015,43(9):940-945.
[51]Eyre DW,Cule ML,Wilson DJ,et al.Diverse sources of C.difficile infection identified on whole-genome sequencing[J].N Engl J Med,2013,369(13):1195-1205.
[52]Grigoras CA,Zervou FN,Zacharioudakis IM,et al.Isolation of C.difficile carriers alone and as part of a bundle approach for the prevention of Clostridium difficile infection(CDI):a mathematical model based on clinical study data[J].PLoSOne,2016,11(6):e0156577.
[53]Malani AN,Richards PG,Kapila S,et al.Clinical and economic outcomes from a community hospital′s antimicrobial stewardship program[J].Am J Infect Control,2013,41(2):145-148.
[54]Richard AM,Raheelah A,Atef SN,et al.A review of quality measures for assessing the impact of antimicrobial stewardship programs in hospitals:[J].Antibiotics,2016,5(1):E5.