Application of the ATLAS score for evaluating the severity of Clostridium difficile infection in teaching hospitals in Mexico

Hernández-García, Raúl; Garza‐González, Elvira; Miller, Mark A.; Arteaga-Müller, Giovanna Yazmin; Santos, Alejandra M. Galván-De los; Camacho-Ortíz, Adrián

doi:10.1016/j.bjid.2015.05.005

Cited by 20 publications

(15 citation statements)

References 12 publications

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“…The frequency of CDI has been on the rise in Asia. In Hong Kong, there has been an annual increase of 26% in cases of CDI from 2006 to 2014 43 . Similar trends have also been reported in South Korea and Taiwan 44 .…”

Section: Discussionsupporting

confidence: 73%

Systematic review on the definition and predictors of severe Clostridiodes difficile infection

Zhang

Woo

Scaduto

et al. 2020

J of Gastro and Hepatol

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Clostridiodes difficile infection (CDI) is one of the most common hospital‐acquired infections with high mortality rates. Optimal management of CDI depends on early recognition of severity. However, currently, there is no acceptable standard of prediction. We reviewed severe CDI predictors in published literature and its definition according to clinical guidelines. We systematically reviewed studies describing clinical predictors for severe CDI in medical databases (Cochrane, EMBASE, Global Health Library, and MEDLINE/PubMed). They were independently evaluated by two reviewers. Six hundred thirty‐three titles and abstracts were screened, and 31 studies were included. We excluded studies that were restricted to a specific patient population. There were 16 articles that examined mortality in CDI, as compared with 15 articles investigating non‐mortality outcomes of CDI. The commonest risk factors identified were comorbidities, white blood cell count, serum albumin level, age, serum creatinine level and intensive care unit admission. Generally, the studies had small patient populations, were retrospective in nature, and mostly from Western centers. The commonest severe CDI criteria in clinical guidelines were raised white blood cell count, followed by low serum albumin and raised serum creatinine levels. There was no commonly agreed upon definition of severe CDI severity in the literature. Current clinical guidelines' definitions for severe CDI are heterogeneous. Hence, there is a need for prospective multi‐center studies using standardized protocol for biospecimen investigation collection and shared data on outcomes of patients in order to devise a universally accepted definition for severe CDI.

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Section: Discussionsupporting

confidence: 73%

Systematic review on the definition and predictors of severe Clostridiodes difficile infection

Zhang

Woo

Scaduto

et al. 2020

J of Gastro and Hepatol

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“…Nonetheless, guidelines are based on expert opinions or systematic reviews and the definitions of severe CDI and its treatment outcomes evaluated in other studies have varied. For example, Zar et al assessed both cure rate and relapse [26]; Bauer et al evaluated treatment failure and recurrence [19]; and ATLAS evaluated cure rate, and its findings were validated in another cohort for mortality and colectomy [15, 28]. Increased levels of WBC (≥15,000 or 30,000 cells/μL) and rise in SCr (1.5-fold high than the premorbid level or absolute value of 1.5 mg/dL), which indicate immune reaction and renal function, are the most common markers between the aforementioned severity criteria [6, 7, 15, 19].…”

Section: Discussionmentioning

confidence: 99%

Risk prediction for 30-day mortality among patients with Clostridium difficile infections: a retrospective cohort study

Chiang

Huang

Chung

et al. 2019

Antimicrob Resist Infect Control

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BackgroundCurrent guidelines have unsatisfied performance in predicting severe outcomes after Clostridium difficile infection (CDI). Our objectives were to develop a risk prediction model for 30-day mortality and to examine its performance among inpatients with CDI.MethodsThis retrospective cohort study was conducted at China Medical University Hospital, a 2111-bed tertiary medical center in central Taiwan. We included adult inpatients who had a first positive C. difficile culture or toxin assay and had diarrhea as the study population. The main exposure of interest was the biochemical profiles of white blood cell count, serum creatinine (SCr), estimated glomerular filtration rate, blood urea nitrogen (BUN), serum albumin, and glucose. The primary outcome was the 30-day all-cause mortality and the secondary outcome was the length of stay in the intensive care units (ICU) following CDI. A multivariable Cox model and a logistic regression model were developed using clinically relevant and statistically significant variables for 30-day mortality and for length of ICU stay, respectively. A risk scoring system was established by standardizing the coefficients. We compared the performance of our models and the guidelines.ResultsOf 401 patients, 23.4% died within 30 days. In the multivariable model, malignancy (hazard ratio [HR] = 1.95), ≥ 1.5-fold rise in SCr (HR = 2.27), BUN-to-SCr ratio > 20 (HR = 2.04), and increased glucose (≥ 193 vs < 142 mg/dL, HR = 2.18) were significant predictors of 30-day mortality. For patients who survived the first 30 days of CDI, BUN-to-SCr ratio > 20 (Odds ratio [OR] = 4.01) was the only significant predictor for prolonged (> 9 days) length of ICU stay following CDI. The Harrell’s c statistic of our Cox model for 30-day mortality (0.727) was significantly superior to those of SHEA-IDSA 2010 (0.645), SHEA-IDSA 2018 (0.591), and ECSMID (0.650). Similarly, the conventional c statistic of our logistic regression model for prolonged ICU stay (0.737) was significantly superior to that of the guidelines (SHEA-IDSA 2010, c = 0.600; SHEA-IDSA 2018, c = 0.634; ESCMID, c = 0.645). Our risk prediction scoring system for 30-day mortality correctly reclassified 20.7, 32.1, and 47.9% of patients, respectively.ConclusionsOur model that included novel biomarkers of BUN-to-SCr ratio and glucose have a higher predictive performance of 30-day mortality and prolonged ICU stay following CDI than do the guidelines.

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“…We next asked if there was an association between antibody levels and disease severity. In the new onset cohort we used the ATLAS (Age, Treatment, Leukocyte count, serum Albumin, Serum creatinine) score as a measure of disease severity 15 , and for the recurrent CDI cohort disease severity was determined using disease course (see methods). We found no associations with disease severity and antibody levels in either cohort ( Figure 1B-C ).…”

Section: Resultsmentioning

confidence: 99%

“…CDI patients received phone follow ups every 14 days for 45 days, to assess for recurrent CDI (initial cessation of diarrhea, followed by recurrence within 45 days from completion of therapy and a positive stool test for C. difficile ). For disease severity classification, individuals with new onset CDI were given an ATLAS score using published criteria 15 . Individuals with recurrent CDI were classified as mild if they never required hospitalization.…”

Section: Methodsmentioning

confidence: 99%

Impaired Th17 immunity in recurrent C. difficile infection is ameliorated by fecal microbial transplantation

Cook

Rees

Wong

et al. 2020

Preprint

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Background & Aims. Clostridioides difficile is a leading cause of infectious diarrhea and an urgent antimicrobial resistant threat. Symptoms are caused by its toxins, TcdA and TcdB, with many patients developing recurrent C. difficile infection (CDI), requiring fecal microbiota transplant (FMT). Antibody levels have not been useful in predicting patient outcomes, which is an unmet need. We aimed to characterize T cell-mediated immunity to C. difficile toxins and assess how these responses were affected by FMT. Methods. We obtained blood samples from patients with newly acquired CDI, recurrent CDI (with a subset receiving FMT), inflammatory bowel disease with no history of CDI, and healthy individuals (controls). Toxin-specific CD4+ T cell responses were analysed using a whole blood flow cytometry antigen-induced marker assay. Serum antibodies were measured by ELISA. Tetramer guided mapping was used to identify HLA-II-restricted TcdB epitopes and DNA was extracted from TcdB-specific CD4+ T cells for TCR repertoire analysis by Sanger sequencing. Results. CD4+ T cell responses to C. difficile toxins were functionally diverse. Compared to controls, individuals with CDI, or inflammatory bowel disease had significantly higher frequencies of TcdB-specific CD4+ T cells. Subjects with recurrent CDI had reduced proportions of TcdB-specific CD4+ Th17 cells, FMT reversed this deficit and increased toxin-specific antibody production. Conclusions. These data suggest that effective T cell immunity to C. difficile requires the development of Th17 cells. In addition, they show that an unknown aspect of the therapeutic effect of FMT may be enhanced T and B cell-mediated immunity to TcdB.

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Application of the ATLAS score for evaluating the severity of Clostridium difficile infection in teaching hospitals in Mexico

Cited by 20 publications

References 12 publications

Systematic review on the definition and predictors of severe Clostridiodes difficile infection

Systematic review on the definition and predictors of severe Clostridiodes difficile infection

Risk prediction for 30-day mortality among patients with Clostridium difficile infections: a retrospective cohort study

Impaired Th17 immunity in recurrent C. difficile infection is ameliorated by fecal microbial transplantation

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