Clostridium difficile infection and Candida colonization of the gut: is there a correlation?

Correspondence Clostridium difficile Infection and Candida Colonization of the Gut: Is There a Correlation? TO THE EDITOR—We read with interest the article of Manian and Bryant about the possible protective role of gut coloni-zation by Candida species against Clos-tridium difficile infection (CDI) [1]. Although Candida has been involved as part of the normal intestinal microbiota [2], no recent data seem to confirm the authors' results. Conversely, an opposite role for non-albicans Candida (NAC) colonization was suggested by Nerandzic et al in a trial on 548 patients with CDI [3]. Recent observations conducted in our 1300-bed teaching hospital Policlinico " Umberto I " in Rome showed that patients treated for severe CDI developed at least 1 episode of candidemia, thus hypothesizing a link between CDI and can-didemia [4]. We designed a prospective case-control study in diarrheic patients with suspected CDI from November 2013 until June 2014 to investigate whether Candida colonization of the gut and CDI may be linked. Stool specimens (n = 140; Bristol stool chart 5–7 [5]) from consecutive patients were evaluated for gluta-mate dehydrogenase and CD toxin A/B by immunochromatography tests (C-Diff Quick Check Complete, Techlab); positive samples were screened for the C. difficile Pa-Loc gene and for 027 ribotype by reverse transcription polymerase chain reaction (RT-PCR) (GeneXpert, Cepheid, Sweden). Candida was revealed by plat-ing 10 µL of all samples on Sabouraud-chloramphenicol agar (Liofilchem, Italy), incubated for 24–48 hours at 37°C. Candi-da colonization was defined as the growth of ≥10 5 colony-forming units per milliliter of stool sample. The yeasts were typed through their biochemical profiles (Api ID 32 C, bioMérieux). Mantel-Haenszel test and Stata 11 software were used for statistical analysis; an α error <.05 was accepted. The 140 patients averaged 65 ± 22.98 years of age, and 52% were male. One hundred patients had negative results and 40 positive results for CDI, as revealed by both the immunochromatogra-phy reactivity and by the RT-PCR for the Pa-Loc gene presence, which showed that 10 patients were infected by the 027 ribo