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Arvand M, Moser V, Schwehn C, Bettge-Weller G, Hensgens MP, Kuijper EJ. High prevalence of Clostridium difficile colonization among nursing home residents in Hesse, Germany. PLoS One 2012; 7:e30183. [PMID: 22253917 PMCID: PMC3256225 DOI: 10.1371/journal.pone.0030183] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 12/15/2011] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile is the most common cause of antibiotic-associated diarrhoea in hospitals and other healthcare facilities. The elderly are particularly susceptible and at increased risk for adverse outcome as a result of C. difficile infection. The aim of this study was to determine the prevalence of C. difficile colonization among residents of nursing homes in Hesse and to compare it with the prevalence in the general population living outside long-term care facilities (LTCF). We assessed possible risk factors for C. difficile colonization and determined the genotype of circulating strains. C. difficile was isolated from 11/240 (4.6%) nursing home residents and 2/249 (0.8%) individuals living outside LTCF (p = 0.02). Ten of 11 (90.9%) isolates from nursing homes and one of two isolates from the population outside LTCF were toxigenic. The prevalence of C. difficile colonization varied from 0% to 10% between different nursing homes. Facilities with known actual or recent CDI cases were more likely to have colonized residents than facilities without known CDI cases. C. difficile PCR-ribotypes 014 and 001 were the most prevalent genotypes and accounted for 30% and 20% of toxigenic isolates in nursing homes, respectively. Interestingly, no individuals carried the epidemic strain PCR-ribotype 027. Our results suggest that residents of nursing homes in Germany are at high risk for colonization by virulent C. difficile strains. The high prevalence of C. difficile colonization in nursing homes underscores the importance of good adherence to standard infection control precautions even in the absence of a diagnosed infection. They also emphasize the need for specific programs to increase the awareness of healthcare professionals in LTCF for CDI.
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Affiliation(s)
- Mardjan Arvand
- Hesse State Health Office, Centre for Health Protection, Dillenburg, Germany.
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102
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Montoya A, Mody L. Common infections in nursing homes: a review of current issues and challenges. AGING HEALTH 2011; 7:889-899. [PMID: 23264804 PMCID: PMC3526889 DOI: 10.2217/ahe.11.80] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Over 1.5 million people live in 16,000 nursing homes in the USA and experience an average of 2 million infections a year. Infections have been associated with high rates of morbidity and mortality, rehospitalization, extended hospital stay and substantial healthcare expenses. Emerging infections and antibiotic-resistant organisms in an institutional environment where there is substantial antimicrobial overuse and the population is older, frailer and sicker, create unique challenges for infection control. This review discusses the common infections, challenges, and a framework for a practical infection prevention program.
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Affiliation(s)
- Ana Montoya
- University of Michigan, Division of Geriatrics, MI, USA
| | - Lona Mody
- University of Michigan, Division of Geriatrics, MI, USA
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103
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Miyajima F, Roberts P, Swale A, Price V, Jones M, Horan M, Beeching N, Brazier J, Parry C, Pendleton N, Pirmohamed M. Characterisation and carriage ratio of Clostridium difficile strains isolated from a community-dwelling elderly population in the United Kingdom. PLoS One 2011; 6:e22804. [PMID: 21886769 PMCID: PMC3160286 DOI: 10.1371/journal.pone.0022804] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 07/06/2011] [Indexed: 12/20/2022] Open
Abstract
Background Community-associated Clostridium difficile infection (CDI) appears to be an increasing problem. Reported carriage rates by C.difficile are debatable with suggestions that primary asymptomatic carriage is associated with decreased risk of subsequent diarrhoea. However, knowledge of potential reservoirs and intestinal carriage rates in the community, particularly in the elderly, the most susceptible group, is limited. We have determined the presence of C.difficile in the faeces of a healthy elderly cohort living outside of long-term care facilities (LCFs) in the United Kingdom. Methods Faecal samples from 149 community-based healthy elderly volunteers (median age 81 years) were screened for C.difficile using direct (Brazier's CCEY) and enrichment (Cooked Meat broth) culture methods and a glutamate dehydrogenase (GDH) immunoassay. Isolates were PCR-ribotyped and analysed for toxin production and the presence of toxin genes. Results Of 149 faecal samples submitted, six (4%) were found to contain C.difficile. One particular sample was positive by both the GDH immunoassay and direct culture, and concurrently produced two distinct strain types: one toxigenic and the other non-toxigenic. The other five samples were only positive by enrichment culture method. Overall, four C.difficile isolates were non-toxigenic (PCR-ribotypes 009, 026 (n = 2) and 039), while three were toxigenic (PCR-ribotypes 003, 005 and 106). All individuals who had a positive culture were symptom-free and none of them had a history of CDI and/or antibiotics use in the 3 month period preceding recruitment. Conclusions To our knowledge, this is the first study of the presence of C.difficile in healthy elderly community-dwelling individuals residing outside of LCFs. The observed carriage rate is lower than that reported for individuals in LCFs and interestingly no individual carried the common epidemic strain PCR-ribotype 027 (NAP1/BI). Further follow-up of asymptomatic carriers in the community, is required to evaluate host susceptibility to CDI and identify dynamic changes in the host and microbial environment that are associated with pathogenicity.
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Affiliation(s)
- Fabio Miyajima
- National Institute for Health Research (NIHR) Biomedical Research Centre, Royal Liverpool and Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool, United Kingdom
- Department of Pharmacology, The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Paul Roberts
- National Institute for Health Research (NIHR) Biomedical Research Centre, Royal Liverpool and Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool, United Kingdom
- Directorate of Infection and Immunity, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Andrew Swale
- National Institute for Health Research (NIHR) Biomedical Research Centre, Royal Liverpool and Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool, United Kingdom
- Department of Pharmacology, The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Valerie Price
- National Institute for Health Research (NIHR) Biomedical Research Centre, Royal Liverpool and Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool, United Kingdom
- Directorate of Infection and Immunity, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Maureen Jones
- Neurodegeneration Research Group, School of Community-Based Medicine, University of Manchester, Manchester, United Kingdom
| | - Michael Horan
- Neurodegeneration Research Group, School of Community-Based Medicine, University of Manchester, Manchester, United Kingdom
| | - Nicholas Beeching
- National Institute for Health Research (NIHR) Biomedical Research Centre, Royal Liverpool and Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool, United Kingdom
- Clinical Group, Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jonathan Brazier
- Anaerobe Reference Unit, Public Health Laboratory, University Hospital Wales, Cardiff, United Kingdom
| | - Christopher Parry
- National Institute for Health Research (NIHR) Biomedical Research Centre, Royal Liverpool and Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool, United Kingdom
- Division of Clinical Infection, Microbiology and Immunology, Institute of Global Health, University of Liverpool, Liverpool, United Kingdom
- Wellcome Trust Major Overseas Programme, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Neil Pendleton
- Neurodegeneration Research Group, School of Community-Based Medicine, University of Manchester, Manchester, United Kingdom
| | - Munir Pirmohamed
- National Institute for Health Research (NIHR) Biomedical Research Centre, Royal Liverpool and Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool, United Kingdom
- Department of Pharmacology, The Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, United Kingdom
- * E-mail:
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Vergidis P, Hamer DH, Meydani SN, Dallal GE, Barlam TF. Patterns of antimicrobial use for respiratory tract infections in older residents of long-term care facilities. J Am Geriatr Soc 2011; 59:1093-8. [PMID: 21539527 PMCID: PMC3325608 DOI: 10.1111/j.1532-5415.2011.03406.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe patterns of antimicrobial use for respiratory tract infections (RTIs) in older residents of long-term care facilities (LTCFs). DESIGN Data from a prospective, randomized, controlled study of the effect of vitamin E supplementation on RTIs conducted from April 1998 through August 2001 were analyzed. SETTING Thirty-three LTCFs in the greater Boston area. PARTICIPANTS Six hundred seventeen subjects aged 65 and older residing in LTCFs. MEASUREMENTS RTIs, categorized as acute bronchitis, pneumonia, common cold, influenza-like illness, pharyngitis, and sinusitis, were studied for appropriateness of antimicrobial use, type of antibiotics used, and factors associated with their use. For cases in which drug treatment was administered, antibiotic use was rated as appropriate (when an effective drug was used), inappropriate (when a more-effective drug was indicated), or unjustified (when use of any antimicrobial was not indicated). RESULTS Of 752 documented episodes of RTI, overall treatment was appropriate in 79% of episodes, inappropriate in 2%, and unjustified in 19%. For acute bronchitis, treatment was appropriate in 35% and unjustified in 65% of cases. For pneumonia, treatment was appropriate in 87% of episodes. Of the most commonly used antimicrobials, macrolide use was unjustified in 43% of cases. No statistically significant differences in the patterns of antibiotic use were observed when stratified according to age, sex, race, or comorbid conditions, including diabetes mellitus, dementia, and chronic kidney disease. CONCLUSION Antimicrobials were unjustifiably used for one-fifth of RTIs and more than two-thirds of cases of acute bronchitis, suggesting a need for programs to improve antibiotic prescribing at LTCFs.
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Affiliation(s)
- Paschalis Vergidis
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Davidson H. Hamer
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of International Health, Boston University School of Public Health, Boston, Massachusetts
- Center for Global Health & Development, Boston University, Boston, Massachusetts
- Jean Mayer USDA Human Nutrition Research Center on the Aging, Tufts University, Boston, Massachusetts
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Simin N. Meydani
- Jean Mayer USDA Human Nutrition Research Center on the Aging, Tufts University, Boston, Massachusetts
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
- Department of Pathology, Sackler Graduate School of Biochemical Sciences, Tufts University, Boston, Massachusetts
| | - Gerard E. Dallal
- Jean Mayer USDA Human Nutrition Research Center on the Aging, Tufts University, Boston, Massachusetts
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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105
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Characterization of cases of Clostridium difficile infection (CDI) presenting at an emergency room: molecular and clinical features differentiate community-onset hospital-associated and community-associated CDI in a tertiary care hospital. J Clin Microbiol 2011; 49:2161-5. [PMID: 21471341 DOI: 10.1128/jcm.02330-10] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Definition of community-onset, hospital-acquired Clostridium difficile infection (CO-HA-CDI) is difficult in patients presenting with diarrhea at hospitals or outpatient clinics, especially 4 to 12 weeks after the last discharge. We performed C. difficile stool culture for 272 diarrheic patients visiting the emergency room (ER) between January 2006 and June 2010. C. difficile was isolated from 36 cases (13.2%), and isolation rates increased year by year, from 10.1% in 2008 to 12.4% in 2009 and 16.7% in 2010. Among 32 toxin-positive isolates, 13 (40.6%) and 19 (59.4%) were associated with CO-HA-CDI and community-acquired CDI (CA-CDI), respectively, if cases with CDI diagnosed within 12 weeks after discharge were considered hospital associated. The majority (70%) of CO-HA-CDI cases occurred within 2 weeks after hospital discharge, although the interval from discharge to onset of symptoms was as long as 10 weeks. We found via tcdA and tcdB and repetitive sequence PCR analysis, that toxin A-positive/toxin B-positive isolates were the most prevalent in both CO-HA-CDI (53.8%) and CA-CDI (94.7%) cases. Toxin A-negative/toxin B-positive isolates were also still highly associated with HA-CDI cases but were also observed in CA-CDI cases. Younger age, fewer underlying diseases, lack of prior antibiotic use, and genetic diversity of isolates in repetitive sequence PCR were the main characteristics in CA-CDI cases visiting the ER.
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106
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Hsu J, Abad C, Dinh M, Safdar N. Prevention of endemic healthcare-associated Clostridium difficile infection: reviewing the evidence. Am J Gastroenterol 2010; 105:2327-39; quiz 2340. [PMID: 20606676 DOI: 10.1038/ajg.2010.254] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Clostridium difficile is the most common infectious cause of healthcare-associated diarrhea. Because of the increasing incidence and severity of endemic C. difficile infection (CDI), interventions to prevent healthcare-associated CDI are essential. We undertook a systematic review of interventions to reduce healthcare-associated CDI. METHODS We searched multiple computerized databases, and manually searched for relevant articles to determine which interventions are useful in preventing CDI. Studies were required to be controlled in design and to report the incidence of endemic CDI as an outcome. Data on the patient population, intervention, study design, and outcomes were abstracted and reviewed using established criteria. RESULTS Few randomized controlled trials exist in the area of CDI prevention. The interventions with the greatest evidence for the prevention of CDI include antimicrobial stewardship, glove use, and disposable thermometers. Environmental decontamination also may decrease CDI rates, although the level of evidence is not as strong as for the other proven interventions. Treatment of asymptomatic carriage of C. difficile is not recommended. There is insufficient evidence to make a recommendation for or against the use of probiotics. In cases of known or suspected CDI, hand hygiene with soap and water is preferred over use of waterless alcohol hand rub. Many nonrandomized trials included in our analysis used multiple interventions concurrently, making the independent role of each preventive strategy difficult to determine. We chose to include only studies that focused on endemic CDI because studies of outbreaks have used multiple strategies, making it difficult to measure the relative efficacy of each strategy. Environmental disinfection and probiotics need to be studied further to evaluate their roles in the prevention of CDI. Although there have been no studies assessing the utility of isolation and cohorting for the prevention of endemic CDI specifically, it is a widely used intervention for containment of this and other similar multidrug-resistant pathogens. CONCLUSIONS Antimicrobial stewardship, glove use, hand hygiene, and disposable thermometers should be routinely used for the prevention of CDI. Environmental disinfection and probiotics should be studied further for their role in reducing CDI.
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Affiliation(s)
- J Hsu
- Section of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792, USA
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107
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Mitu-Pretorian O, Forgacs B, Qumruddin A, Tavakoli A, Augustine T, Pararajasingam R. Outcomes of Patients Who Develop Symptomatic Clostridium difficile Infection After Solid Organ Transplantation. Transplant Proc 2010; 42:2631-3. [DOI: 10.1016/j.transproceed.2010.04.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Accepted: 04/11/2010] [Indexed: 10/19/2022]
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108
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Simor AE. Diagnosis, Management, and Prevention of Clostridium difficile Infection in Long-Term Care Facilities: A Review. J Am Geriatr Soc 2010; 58:1556-64. [DOI: 10.1111/j.1532-5415.2010.02958.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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109
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Diggs NG, Surawicz CM. Clostridium difficileinfection: still principally a disease of the elderly. ACTA ACUST UNITED AC 2010. [DOI: 10.2217/thy.10.17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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110
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Archbald-Pannone L, Sevilleja JE, Guerrant R. Diarrhea, clostridium difficile, and intestinal inflammation in residents of a long-term care facility. J Am Med Dir Assoc 2010; 11:263-7. [PMID: 20439046 DOI: 10.1016/j.jamda.2009.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 09/02/2009] [Accepted: 09/04/2009] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Long-term care facilities (LTCF) residents have been estimated to have the highest incidence of diarrheal illness among adults living in the developed world. This study describes undiagnosed diarrhea, intestinal inflammation, and Clostridium difficile colonization in a LTC population and explores whether these are associated with functional decline, as defined by weight loss or a change in cognitive or ADL status. METHODS An observational study of a convenience sampling of residents in a 180-bed LTCF was obtained; evaluation of stool and medical records was done. Stool specimens were evaluated for consistency, gross blood, inflammation (via quantitative fecal lactoferrin, IBD-SCAN), and C difficile (via PCR for gdh). SPSS and STATA were used and significance was set at P < .05. RESULTS There were 46 stools collected; 13 of the subjects were male, 28 were older than 65 years, and 35 were prescribed 5 to 15 medications. Twenty-six of the 46 stools collected had elevated quantitative fecal lactoferrin levels. Although only 5 subjects were reported to have diarrhea (4 with elevated lactoferrin), 28 stool specimens were observed to be liquid or semi-solid (19 with elevated lactoferrin), and these liquid/ semisolid stools were significantly correlated with lactoferrin positivity (P = .017). In analysis of functional status, there was no statistically significant association between change in ADL (n = 17) or cognitive status (n = 5) and elevated lactoferrin. However, all 3 subjects who had significant weight loss had elevated lactoferrin, although the mean fecal lactoferrin was not statistically different from those without weight loss. Of the 2 samples with C difficile, both were liquid and, when compared with all other liquid stools (n = 22), the mean lactoferrin was statistically higher (134.1 versus 28.8 microg/mL, P = .008). These 2 subjects had neither weight loss nor change in cognitive status, but 1 had a change in ADL status. DISCUSSION AND CONCLUSIONS Diarrhea in LTCF residents is underdiagnosed. Diarrhea and the presence of C difficile in the stool are associated with intestinal inflammation, as detected by fecal lactoferrin. With our small numbers, we were not able to identify a specific link; however, we were able to identify a correlation between weight loss and intestinal inflammation, but, with just 2 samples, not C difficile colonization. This relationship highlights the importance of larger studies to further examine the rate of diarrhea in LTCF; the effect of diarrhea and intestinal inflammation on weight loss; and the interaction of C difficile colonization with weight loss, malnutrition, and functional decline.
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Affiliation(s)
- Laurie Archbald-Pannone
- University of Virginia, Department of Internal Medicine, Division of General Medicine, Section of Geriatrics, Charlottesville, VA 22908, USA.
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111
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Abstract
Older patients disproportionately suffer the burden of infection in the community and in health care facilities. The rational approach to antimicrobial therapy for older patients with infection requires an appreciation and understanding of the complex immunologic, epidemiologic, pharmacologic, and microbiologic factors that influence the manifestations and consequences of infection in this group. Specific recommendations for common infectious syndromes must take into account the unique needs of older patients and should be tailored for each individual case.
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112
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Abstract
A recent report by the Department of Health, Clostridium Difficile Infection: How to deal with the problem - a board to ward approach, is a revised set of guidelines based on best practice and key recommendations for the NHS to ensure the control of Clostridium difficile infection (CDI). It takes into account a national framework for clinical governance which did not previously exist, a framework that gives significant weight to infection control as a matter of patient safety, and highlights that all clinicians have a personal responsibility for infection prevention and control. It puts the onus on Trust management and PCTs to ensure that measures are in place to prevent and manage CDI according to best evidence. However, the report fails to explain how these measures will have an impact on finance and resources on an already burdened system. The author explains how much of the report is comparable with the one published in 1994, and highlights many of its limitations within the busy hospital setting. Reducing CDI is achievable, as many hospitals are showing large reductions in their CDI rates. Healthcare workers must be applauded for their success in reducing CDI, but there is more to be done.
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Affiliation(s)
- Ann-Marie Aziz
- University Hospital South Manchester NHS Foundation Trust, UK
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113
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Abstract
Clostridium difficile is the most common cause of infectious diarrhea in hospitalized patients. Its effects are mediated by C difficile toxins A and B. Recent outbreaks of severe colitis have been associated with a new strain of the bacterium that produces large amounts of the toxins. Although oral metronidazole and oral vancomycin can be used to treat C difficile-associated disease, intraluminal vancomycin is preferable for more severe C difficile colitis. Early surgical intervention can improve outcomes with fulminant colitis, although overall mortality remains high.
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Affiliation(s)
- Philip A Efron
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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114
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Dubberke ER, McMullen KM, Mayfield JL, Reske KA, Georgantopoulos P, Warren DK, Fraser VJ. Hospital-associated Clostridium difficile infection: is it necessary to track community-onset disease? Infect Control Hosp Epidemiol 2009; 30:332-7. [PMID: 19239377 DOI: 10.1086/596604] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To compare Clostridium difficile infection (CDI) rates determined with use of a traditional definition (ie, with healthcare-onset CDI defined as diagnosis of CDI more than 48 hours after hospital admission) with rates determined with use of expanded definitions, including both healthcare-onset CDI and community-onset CDI, diagnosed within 48 hours after hospital admission in patients who were hospitalized in the previous 30 or 60 days, and to determine whether differences exist between patients with CDI onset in the community and those with CDI onset in a healthcare setting. DESIGN Prospective cohort. SETTING Tertiary acute care facility. PATIENTS General medicine patients who received a diagnosis of CDI during the period January 1, 2004, through December 31, 2005. METHODS CDI was classified as healthcare-onset CDI, healthcare facility-associated CDI after hospitalization within the previous 30 days, and/or healthcare facility-associated CDI after hospitalization within the previous 60 days. Patient demographic characteristics and medication exposures were obtained. The CDI incidence with use of each definition, CDI rate variability, patient demographic characteristics, and medication exposures were compared. RESULTS The healthcare-onset CDI rate (1.6 cases per 1,000 patient-days) was significantly lower than the 30-day healthcare facility-associated CDI rate (2.4 cases per 1,000 patient-days; P< .01) and the 60-day healthcare facility-associated CDI rate (2.6 cases per 1,000 patient-days; P< .01). There was good correlation between the healthcare-onset CDI rate and both the 30-day (correlation, 0.69; P< .01) and 60-day (correlation, 0.70; P< .01) healthcare facility-associated CDI rates. There were no months in which the CDI rate was more than 3 standard deviations from the mean. Compared with patients with healthcare-onset CDI, patients with community-onset CDI were less likely to have received a fourth-generation cephalosporin (P= .02) or intravenous vancomycin (P+ .01) during hospitalization. CONCLUSIONS Compared with the traditional definition, expanded definitions identify more patients with CDI. There is good correlation between traditional and expanded CDI definitions; therefore, it is unclear whether expanded surveillance is necessary to identify an abnormal change in CDI rates. Cases that met the expanded definitions were less likely to have occurred in patients with fourth-generation cephalosporin and vancomycin exposure.
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Affiliation(s)
- Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri, USA.
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115
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Pawlowski SW, Warren CA, Guerrant R. Diagnosis and treatment of acute or persistent diarrhea. Gastroenterology 2009; 136:1874-86. [PMID: 19457416 PMCID: PMC2723735 DOI: 10.1053/j.gastro.2009.02.072] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 02/03/2009] [Accepted: 02/25/2009] [Indexed: 01/10/2023]
Abstract
Studies of microbial pathogens and the toxins they produce are important for determining the mechanisms by which they cause disease and spread throughout a population. Some bacteria produce secretory enterotoxins (such as cholera toxin or the heat-labile or stable enterotoxins produced by Escherichia coli) that invade cells directly. Others invade cells or produce cytotoxins (such as those produced by Shigella, enteroinvasive E coli, or Clostridium difficile) that damage cells or trigger host responses that cause small or large bowel diseases (such as enteroaggregative or enteropathogenic E coli or Salmonella). Viruses (such as noroviruses and rotaviruses) and protozoa (such as Cryptosporidium, Giardia, or Entamoeba histolytica) disrupt cell functions and cause short- or long-term disease. Much epidemiologic data about these pathogens have been collected from community- and hospital-acquired settings, as well as from patients with traveler's or persistent diarrhea. These studies have led to practical approaches for prevention, diagnosis, and treatment.
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Key Words
- camp, cyclic adenosine 3′,5′ monophosphate
- cdi, clostridium difficile infection
- eaec, enteroaggregative escherichia coli
- ehec, enterohemorrhagic escherichia coli
- eiec, enteroinvasive escherichia coli
- elisa, enzyme-linked immunoabsorbent assay
- epec, enteropathogenic escherichia coli
- etec, enterotoxigenic escherichia coli
- gi, gastrointestinal
- pcr, polymerase chain reaction
- pi-ibs, postinfectious irritable bowel syndrome
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Affiliation(s)
| | | | - Richard Guerrant
- Reprint requests Address requests for reprints to: Richard Guerrant, Center for Global Health, Division of Infectious Disease and International Health, University of Virginia School of Medicine, Charlottesville, Virginia 22908. fax: (434) 982-0591
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High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc 2009; 57:375-94. [PMID: 19278394 PMCID: PMC7166905 DOI: 10.1111/j.1532-5415.2009.02175.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Residents of long‐term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one‐half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on‐site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.
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Affiliation(s)
- Kevin P High
- Section on Infectious Diseases, Wake Forest University Health Sciences, Winston Salem, North Carolina 27157-1042, USA.
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117
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Diarrhea in long-term care: a messy problem. J Am Med Dir Assoc 2009; 10:213-7. [PMID: 19426933 DOI: 10.1016/j.jamda.2009.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 01/21/2009] [Indexed: 01/30/2023]
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118
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High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc 2009. [PMID: 19278394 DOI: 10.1111/j.1532‐5415.2009.02175.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.
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Affiliation(s)
- Kevin P High
- Section on Infectious Diseases, Wake Forest University Health Sciences, Winston Salem, North Carolina 27157-1042, USA.
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119
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Weiss K, Boisvert A, Chagnon M, Duchesne C, Habash S, Lepage Y, Letourneau J, Raty J, Savoie M. Multipronged intervention strategy to control an outbreak of Clostridium difficile infection (CDI) and its impact on the rates of CDI from 2002 to 2007. Infect Control Hosp Epidemiol 2009; 30:156-62. [PMID: 19125681 DOI: 10.1086/593955] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE At the end of 2002, a new, more virulent strain of Clostridium difficile, designated BI/NAP1, was the cause of a massive outbreak of infection in the province of Quebec. This particular strain was associated with a dramatic increase in morbidity and mortality among affected patients in 2003-2004. We tested and implemented a multipronged infection control approach to curtail the rate of C. difficile infection (CDI). DESIGN Five-year observational study. SETTING A 554-bed, acute care tertiary hospital, the largest single medical center in Quebec, Canada. METHODS To curtail the magnitude of the outbreak, we implemented a global strategy consisting of rapid C. difficile testing for all hospitalized patients who had at least 1 occurrence of liquid stool, the rapid isolation of patients infected with C. difficile in a dedicated ward with a specially trained housekeeping team, a global hand hygiene program, and the hiring of infection control practitioners. Antibiotic consumption at the institutional level was also monitored during the 5-year surveillance period. Cases of hospital-acquired CDI per 1,000 admissions were continuously monitored on a monthly basis during the entire surveillance period. RESULTS The highest recorded CDI rate was 42 cases per 1,000 admissions in January 2004. Once additional infection control resources were put in place, the rate decreased significantly during the period from April 2005 to March 2007. During the 2003-2004 period, there were 762 cases of CDI (mean annual rate, 37.28 cases per 1,000 admissions) recorded in our study, compared with 292 cases of CDI (14.48 cases per 1,000 admissions) during the 2006-2007 period (OR, 0.379 [95% CI, 0.331-0.435]; p< .001), a 61% reduction. In March 2007, the equivalent of 4 full-time equivalent infection control practitioners were in place, which gave a ratio of 0.96 infection control practitioners per 133 beds in use, compared with the ratio of 0.24 infection control practitioners per 133 beds in use in 2003, and the total number of hours dedicated to cleaning and housekeeping increased by 26.2%. The total amount of antibiotics used in the hospital did not vary significantly from 2002 to 2007, although there were changes in the classes antibiotic used. CONCLUSION The implementation of a multipronged intervention strategy to control the outbreak of CDI significantly improved the overall situation at the hospital and underlined the importance of investing in stringent infection control practices.
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Affiliation(s)
- Karl Weiss
- Department of Infectious Diseases and Microbiology, Maisonneuve-Rosemont Hospital, Faculty of Medicine, Montreal, Quebec, Canada.
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120
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Abstract
PURPOSE OF REVIEW To provide a general understanding of Clostridium difficile infection with a focus on recent publications that evaluate the disease in solid organ transplant recipients. RECENT FINDINGS The incidence of C. difficile infection is increasing worldwide. Epidemics due to a hypervirulent C. difficile strain are associated with an escalating severity of disease. New evidence further supports basing initial treatment choice on disease severity. SUMMARY C. difficile is a significant pathogen in solid organ transplant recipients. Multiple risk factors are found in this population that may result in more severe disease. A high index of suspicion is necessary for the early diagnosis and treatment of C. difficile infection in transplant recipients. Metronidazole and vancomycin show equivalent efficacy in the treatment for mild-to-moderate disease, but vancomycin has demonstrated superiority in the treatment of severe disease. Surgical intervention is also an important consideration in the treatment of solid organ transplant recipients with severe colitis. Rigorous infection control practices are essential for preventing the spread of C. difficile within the hospital environment.
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121
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Tebbutt GM, Wilson D, Holtby I. A study of 279 general outbreaks of gastrointestinal infection in the north-East region of England. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2009; 6:547-57. [PMID: 19440398 PMCID: PMC2672363 DOI: 10.3390/ijerph6020547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Accepted: 02/03/2009] [Indexed: 11/25/2022]
Abstract
All outbreaks of infectious intestinal disease reported to the authorities were entered on a computer database with outbreak control teams being established to investigate larger or more significant incidents. The outbreak database and, when set up, the notes of outbreak team meetings were examined for the 279 outbreaks reported in a three-year period (2003–2005). Faeces specimens submitted as part of an outbreak were examined for microbial pathogens and the results cross-matched to the outbreak number. Almost half of the general outbreaks reported (137) occurred in long-term care facilities for the elderly, 51 outbreaks were recorded in hospitals and 31 occurred in the wider community. In 76 outbreaks no specimen was logged. A microbial cause was confirmed in about one-third of outbreaks, with noroviruses being the most common (19%). Salmonellas accounted for 12 of the 21 community outbreaks linked to social events and all were foodborne. Suggestions for improving notification and surveillance are discussed.
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Affiliation(s)
- Grahame M. Tebbutt
- HPA North East, Newcastle Laboratory, Institute of Pathology, Newcastle General Hospital, Newcastle-upon-Tyne NE4 6BE, UK
- Author to whom correspondence should be addressed; E-Mail:
; Tel.: +44-1289-308071
| | - Deborah Wilson
- County Durham and Tees Valley Health Protection Unit, Appleton House, Lanchester Road, Durham DH1 5XZ, UK; E-Mail:
| | - Ian Holtby
- County Durham and Tees Valley Health Protection Unit, Poole House, Stokesley Road, Middlesbrough TS7 0NJ, UK; E-Mail:
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122
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Abstract
In the long-term care setting The diagnosis of infection is primarily based from the clinical assessment. Infection is a common cause of fever, when present, and acute change in functional status. Infection can often present atypically; usual symptoms, physical findings, and diagnostic abnormalities may be lacking. Evaluation of fever and suspected infection should initially focus on the most common clinical syndromes. Treatment should initially focus on the most common organisms that are present at the most likely suspect site of infection.
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123
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High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48:149-71. [PMID: 19072244 DOI: 10.1086/595683] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.
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Affiliation(s)
- Kevin P High
- Section on Infectious Diseases, Wake Forest University Health Sciences, Winston Salem, 100 Medical Center Blvd., Winston Salem, NC 27157-1042, USA.
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124
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Dubberke ER, Gerding DN, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Fraser V, Griffin FA, Gross P, Kaye KS, Klompas M, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2009; 29 Suppl 1:S81-92. [PMID: 18840091 DOI: 10.1086/591065] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri, USA
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125
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Abstract
INTRODUCTION/BACKGROUND Clostridium difficile is the commonest cause of nosocomial diarrhoea. The epidemiology and clinical phenotype of the disease has dramatically changed with the global emergence of a virulent strain of C. difficile. SOURCE This review was compiled using data from individual studies and review articles identified from PubMed. The retrieved articles were also examined for additional references. AREAS OF AGREEMENT Appropriate and timely infection control measures are required to control C. difficile infection (CDI) in the hospital environment, and either oral metronidazole or vancomycin remains the mainstay of treatment depending on the severity of infection. AREAS OF CONTROVERSY The optimal method for diagnosing CDI remains unclear, as does the best therapeutic strategy for the management of multiple relapses. GROWING POINTS/AREAS TIMELY FOR DEVELOPING RESEARCH: Studies of new antimicrobial agents with activity against C. difficile are required to improve the management of multiply relapsing disease. The use of novel therapeutic approaches that do not require antimicrobials requires urgent research, including the use of immunological or vaccine-based regimen, bacteriotherapy or C. difficile-specific bacteriophages.
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Affiliation(s)
- O Martin Williams
- Health Protection Agency Regional Laboratory South West, Level 8, Queens Building, Bristol Royal Infirmary Marlborough Street, Bristol BS2 8HW, UK
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126
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Smith PW, Bennett G, Bradley S, Drinka P, Lautenbach E, Marx J, Mody L, Nicolle L, Stevenson K. SHEA/APIC guideline: infection prevention and control in the long-term care facility, July 2008. Infect Control Hosp Epidemiol 2008; 29:785-814. [PMID: 18767983 PMCID: PMC3319407 DOI: 10.1086/592416] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Philip W Smith
- Professor of Infectious Diseases, Colleges of Medicine and Public Health, University of Nebraska Medical Center, Omaha, Nebraska 68198-5400, USA.
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127
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Howitt JR, Grace JW, Schaefer MG, Dolder C, Cannella C, Schaefer RS. Clostridium difficile-positive stools: a retrospective identification of risk factors. Am J Infect Control 2008; 36:488-91. [PMID: 18786452 DOI: 10.1016/j.ajic.2007.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Revised: 09/12/2007] [Accepted: 09/12/2007] [Indexed: 11/30/2022]
Abstract
In an attempt to determine the association of potential risk factors and an increase in the rate of Clostridium difficile-associated diarrhea (CDAD) at a tertiary teaching institution in the Midwest United States, all CDAD cases among admissions from a period of 20 consecutive months were analyzed. A retrospective chart review was performed on 4992 admissions from this period. Logistic regression analysis suggested a correlation between CDAD and multiple factors.
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Affiliation(s)
- Joshua R Howitt
- Pharmacy, Department of Veteran's Affairs Medical Center, Kansas City, MO 64128, USA.
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128
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Smith PW, Bennett G, Bradley S, Drinka P, Lautenbach E, Marx J, Mody L, Nicolle L, Stevenson K. SHEA/APIC Guideline: Infection prevention and control in the long-term care facility. Am J Infect Control 2008; 36:504-35. [PMID: 18786461 PMCID: PMC3375028 DOI: 10.1016/j.ajic.2008.06.001] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Revised: 05/07/2008] [Accepted: 05/19/2008] [Indexed: 01/09/2023]
Affiliation(s)
- Philip W Smith
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198-5400, USA.
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129
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Thorson MAL, Bliss DZ, Savik K. Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients. J Adv Nurs 2008; 62:354-64. [PMID: 18426460 DOI: 10.1111/j.1365-2648.2008.04607.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
AIM This paper is a report of a study to determine the incidence of non-Clostridium difficile-associated diarrhoea in hospitalized patients and to re-evaluate clinical characteristics and other risk factors related to non-C. difficile-associated diarrhoea. BACKGROUND Numerous factors are thought to be responsible for diarrhoea in hospitalized patients. Reports about the diarrhoeal effects of some medications administered concomitantly with tube feeding have stimulated reappraisal of the influence of tube feeding as a potential cause. METHOD This study was a secondary analysis of data of 154 hospitalized patients collected during a prospective epidemiological study from 1992 to 1993. The secondary analysis was completed in 2006 in order to investigate unanswered questions of current importance. FINDINGS The sample was predominantly male and middle aged; approximately 50% were tube fed, and 25% were in an intensive care unit. The incidence of diarrhoea was 35%. Increased severity of illness as well as the combination of sorbitol-containing medication administration and tube feeding were found to be statistically significant factors in the development of diarrhoea. CONCLUSION As diarrhoea in hospitalized patients appears to be multifactorial, use of an algorithm to systematically evaluate and manage related factors is recommended.
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130
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Dubberke E, Reske K, Yan Y, Olsen M, Fraser V. Reply to Goorhuis et al. Clin Infect Dis 2008. [DOI: 10.1086/589929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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131
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Is your patient taking the right antimicrobial? Am J Nurs 2008; 108:49-55. [PMID: 18535447 DOI: 10.1097/01.naj.0000324377.09651.c7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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132
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Wilcox MH, Mooney L, Bendall R, Settle CD, Fawley WN. A case-control study of community-associated Clostridium difficile infection. J Antimicrob Chemother 2008; 62:388-96. [PMID: 18434341 DOI: 10.1093/jac/dkn163] [Citation(s) in RCA: 289] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim of this study was to determine the incidence of and risk factors for community-associated Clostridium difficile infection (CDI). METHODS Prospective surveillance of community-derived faecal samples for C. difficile cytotoxin, followed by a questionnaire-based case-control study in two distinct patient cohorts (one semi-rural and the other urban). RESULTS The proportion of randomly selected faecal samples positive for C. difficile cytotoxin was 2.1% in both patient cohorts (median ages 73 and 45 years for the urban and semi-rural cohorts, respectively). Exposure to antibiotics in the previous 4 weeks, particularly multiple agents (P < 0.001), aminopenicillins (P < 0.05) and oral cephalosporins (P < 0.05), was significantly more frequent among cases than controls. Hospitalization in the preceding 6 months was significantly associated with CDI (45% versus 23%; P = 0.022). However, almost half the cases had not received antibiotic therapy in the month before C. difficile detection, and approximately one-third neither had exposure to antibiotics nor recent hospitalization. Contact with infants aged < or =2 years was significantly associated with CDI (14% versus 2%; P = 0.02). Prior exposure to gastrointestinal-acting drugs (proton pump inhibitor, H2 antagonist or non-steroidal anti-inflammatory) was not significantly more common in CDI cases. C. difficile PCR ribotype 001 caused 60% and 13% of urban and semi-rural community-associated CDI cases, respectively. CONCLUSIONS Reliance on antibiotic history and age (> or =65 years) will contribute to missed diagnoses of community-associated CDI. Potential risk factors for community-associated CDI should be explored further to explain the large proportion of cases not linked to recent antibiotic therapy or hospitalization.
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Affiliation(s)
- M H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals, Old Medical School, Leeds LS1 3EX, UK.
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133
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The changing spectrum of clostridium difficile associated disease: implications for dentistry. J Am Dent Assoc 2008; 139:42-7. [PMID: 18167383 DOI: 10.14219/jada.archive.2008.0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Clostridium difficile is an anaerobic, spore-forming bacterium that causes a wide range of diseases of the gastrointestinal tract. It is best known for its association with uncomplicated antimicrobial-agent-associated diarrhea. CASE DESCRIPTION The authors describe two previously published cases of Clostridium difficile-associated disease (CDAD) to highlight its varied clinical manifestations. A 48-year-old woman had mild CDAD after receiving antibiotics after undergoing endodontic surgery. She took metronidazole, and her C. difficile infection resolved. A 31-year-old pregnant woman developed severe CDAD after receiving antibiotics for a urinary tract infection. She underwent surgery to remove part of her colon, but her condition worsened, and she died. CLINICAL IMPLICATIONS Dentists often prescribe antimicrobial agents to treat infections. Until recently, these agents also were recommended as prophylaxis for infective endocarditis during invasive oral procedures. An important risk factor for CDAD and recurrent CDAD is antimicrobial agent exposure. Dentists should be aware of CDAD to help prevent its spread and facilitate early recognition and treatment to minimize severe outcomes.
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134
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Bartlett JG, Gerding DN. Clinical recognition and diagnosis of Clostridium difficile infection. Clin Infect Dis 2008; 46 Suppl 1:S12-8. [PMID: 18177217 DOI: 10.1086/521863] [Citation(s) in RCA: 381] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Prompt and precise diagnosis is an important aspect of effective management of Clostridium difficile infection (CDI). CDI causes 15%-25% of all cases of antibiotic-associated diarrhea, the severity of which ranges from mild diarrhea to fulminant pseudomembranous colitis. Several factors, especially advanced age and hospitalization, should be considered in the diagnosis of CDI. In particular, nosocomial diarrhea arising >72 hours after admission among patients receiving antibiotics is highly likely to have resulted from CDI. Testing of stool for the presence of C. difficile toxin confirms the diagnosis of CDI. However, performance of an enzyme immunoassay is the usual method by which CDI is confirmed, but this test appears to be relatively insensitive, compared with the cell cytotoxicity assay and stool culture for toxigenic C. difficile on selective medium. Endoscopy and computed tomography are less sensitive than stool toxin assays but may be useful when immediate results are important or other confounding conditions rank high in the differential diagnosis. Often overlooked aspects of this diagnosis are high white blood cell counts (which are sometimes in the leukemoid range) and hypoalbuminemia.
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Affiliation(s)
- John G Bartlett
- Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
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135
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Zerey M, Paton BL, Lincourt AE, Gersin KS, Kercher KW, Heniford BT. The burden of Clostridium difficile in surgical patients in the United States. Surg Infect (Larchmt) 2008; 8:557-66. [PMID: 18171114 DOI: 10.1089/sur.2006.062] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Clostridium difficile colitis is the predominant hospital-acquired gastrointestinal infection in the United States and has emerged as an important nosocomial cause of morbidity and death. Although several institutional studies have examined the effects of C. difficile on hospitalized patients, its nationwide impact on surgical patients has yet to be defined. METHODS To provide a national estimate of the burden of C. difficile, we performed a five-year retrospective analysis of the Agency for Healthcare Research and Quality's National Inpatient Sample Database, which represents a stratified 20% sample of hospitals in the United States, from 1999 to 2003. All surgical inpatient discharge data from 997 hospitals in 37 states were analyzed to determine the association of C. difficile infections with patient demographics, hospital characteristics, surgical procedure, length of stay (LOS), total charges, and in-hospital mortality rate. Univariate analysis was performed to identify any association between the presence of C. difficile infection and the outcome variables using chi-square contingency table analysis or the Student t-test following the exclusion of patients with other medical complications. Multivariate regression analysis was used to determine whether the presence of C. difficile infection was an independent predictor of increased LOS, total charges, and in-hospital mortality rate when controlling for surgery type, age, sex, payor, and hospital characteristics. RESULTS Clostridium difficile infection was reported as a discharge diagnosis for 8,113 (0.52%) of all 1,553,597 inpatients who had undergone a general surgical procedure. The incidence increased significantly in 2002 (34% higher than in 2001; p < 0.0001). The following patient and hospital characteristics were associated with the highest incidence of C. difficile infection (all p < 0.0001): Age > 64 years (0.95%); Medicare beneficiary status (0.94%); north-eastern hospital location (0.73%); and large (0.55%), urban (0.56%), or teaching hospital (0.61%). Patients undergoing an emergency operation were at higher risk than those having operations performed electively (0.8% vs. 0.3%; p < 0.0001). Colectomy, small-bowel resection, and gastric resection were associated with the highest risk of C. difficile infection (incidence after colectomy 1.11%; odds ratio [OR] 2.77, 95% confidence interval [CI] 2.65, 2.89, p < 0.0001; small-bowel resection 1.17%, OR 2.40, 95% CI 2.26, 2.54, p < 0.0001; gastric resection 1.02%, OR 2.26, 95% CI 2.03, 2.52, p < 0.0001). Patients undergoing cholecystectomy and appendectomy had the lowest risk of C. difficile infection (cholecystectomy 0.41%, OR 0.37, 95% CI 0.35, 0.39, p < 0.0001; appendectomy 0.20%, OR 0.45, 95% CI 0.42, 0.49, p < 0.0001). Multivariable analysis demonstrated that C. difficile was an independent predictor of LOS, which increased by 16.0 days (95% CI 15.6, 16.4 days; p < 0.0001) in the presence of infection. Total charges increased by $77,483 (95% CI $75,174, $79,793; p < 0.0001), and there was a 3.4-fold increase in the mortality rate (95% CI 3.02, 3.77; p < 0.0001) compared with patients who did not acquire C. difficile. CONCLUSIONS Epidemiologic data suggest that the incidence of C. difficile infection is increasing in U.S. surgical patients and that the infection is most prevalent after emergency operations and among patients having intestinal tract resections. Infection with C. difficile is an independent predictor of increased LOS, total charges, and mortality rate after surgery and represents a considerable burden to both patients and hospitals. Preventing C. difficile infection offers a potentially significant improvement in patient outcomes, as well as a reduction in hospital costs and resource expenditures.
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Affiliation(s)
- Marc Zerey
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, North Carolina 28203, USA
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136
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Abstract
Diarrhea in the elderly population is one disease that needs special attention in treatment and management, especially in acute- and long-term care residents, because of their multiple comorbidities, immunosenescence, frailty, and poor nutritional status. Close follow-up to ensure adequate hydration and electrolyte replacement and infection control measures to contain outbreaks should be emphasized to caregivers and nursing staff in acute- and long-term care facilities. Although C difficile colitis causes significant morbidity and mortality in this population, judicious use of antibiotics is important to decrease the incidence and recurrence of the disease. When the diarrhea is chronic and all stool testings and serologies have been performed, the patient may benefit from endoscopy and colonoscopy for biopsy. Attentive and vigilant nursing staff is crucial in the timely diagnosis and treatment of diarrheal diseases to improve quality of life and reduce mortality.
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137
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Dubberke ER, Reske KA, Olsen MA, McDonald LC, Fraser VJ. Short- and long-term attributable costs of Clostridium difficile-associated disease in nonsurgical inpatients. Clin Infect Dis 2008; 46:497-504. [PMID: 18197759 DOI: 10.1086/526530] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The incidence of Clostridium difficile-associated disease (CDAD) is increasing. There are few data on the short-term and long-term attributable costs of CDAD. The objective of this study was to determine the acute and 180-day attributable inpatient costs of CDAD. METHODS We performed a retrospective cohort study of all patients without operating room costs who were admitted for > or =48 h to Barnes-Jewish Hospital, a tertiary care hospital in St. Louis, Missouri, 1 January 2003-31 December 2003 (n = 24,691). Attributable costs of CDAD were determined by multivariable linear regression and propensity-score matched-pairs analyses (n = 684) for the hospitalization in which CDAD occurred and per patient over a 180-day period, including the initial hospitalization. RESULTS CDAD was associated with $2454 (95% confidence interval, $2380-$2950; increase in cost, 41%) attributable costs per CDAD episode by linear regression and with $3240 attributable costs (P < .001; increase in cost, 33%) by propensity-score matched-pairs analysis. CDAD was associated with $5042 (95% confidence interval, $3797-$6481; increase in cost, 53%) attributable inpatient costs over 180 days by linear regression and with $7179 attributable costs for inpatient care (P < .001; 48% increase in costs) by propensity-score matched-pairs analysis. CONCLUSIONS CDAD was associated with a significant increase in costs for inpatient care and increased costs at 180 days after the initial hospitalization when the CDAD episode occurred.
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Affiliation(s)
- Erik R Dubberke
- Washington University School of Medicine, Saint Louis, Missouri, USA.
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138
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Gould CV, McDonald LC. Bench-to-bedside review: Clostridium difficile colitis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:203. [PMID: 18279531 PMCID: PMC2374604 DOI: 10.1186/cc6207] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In recent years, the incidence and severity of Clostridium difficile-associated disease (CDAD) have increased dramatically. Beginning in 2000, widespread regional outbreaks associated with a previously uncommon hypervirulent strain of C. difficile have occurred in North America and Europe. Most likely because of increased toxin production as well as other virulence factors, this epidemic strain has caused more severe and refractory disease leading to complications, including intensive care unit admission, colectomies, and death. Worldwide increasing use of fluoroquinolones and cephalosporins has likely contributed to the proliferation of this epidemic strain, which is highly resistant to both. The elderly have been disproportionately affected by CDAD, but C. difficile has also recently emerged in populations previously considered to be at low risk, including healthy outpatients and peripartum women, although it is unknown if these cases are related to the epidemic strain. Nevertheless, transmission within hospitals is the major source of C. difficile acquisition, and previous or concurrent antimicrobial use is almost universal among cases. Applying current evidence-based strategies for management and prevention is critically important, and clinicians should maintain an awareness of the changing epidemiology of CDAD and take measures to reduce the risk of disease in patients.
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Affiliation(s)
- Carolyn V Gould
- Prevention and Response Branch, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Clifton Road NE, Atlanta, GA 30333, USA
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139
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Matheï C, Niclaes L, Suetens C, Jans B, Buntinx F. Infections in residents of nursing homes. Infect Dis Clin North Am 2008; 21:761-72, ix. [PMID: 17826622 DOI: 10.1016/j.idc.2007.07.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Infectious diseases are a very common occurrence in nursing homes. While the reasons for preventing infections are the same in nursing homes and in acute hospitals, several considerations relevant to prevention of infection differ in nursing homes. Infection control measures should be based upon the particularities of the specific setting of a nursing home and its residents.
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Affiliation(s)
- Catharina Matheï
- Department of General Practice, KU Leuven, Kapucijnenvoer 33 blok J, 3000 Leuven, Belgium.
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140
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Riggs MM, Sethi AK, Zabarsky TF, Eckstein EC, Jump RLP, Donskey CJ. Asymptomatic Carriers Are a Potential Source for Transmission of Epidemic and Nonepidemic Clostridium difficile Strains among Long-Term Care Facility Residents. Clin Infect Dis 2007; 45:992-8. [PMID: 17879913 DOI: 10.1086/521854] [Citation(s) in RCA: 395] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 06/11/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Asymptomatic fecal carriage of Clostridium difficile is common in patients staying in health care facilities, but the importance of asymptomatic carriers with regard to disease transmission is unclear. METHODS We prospectively examined the prevalence of asymptomatic carriage of epidemic North American pulsed-field gel electrophoresis type 1 and nonepidemic toxigenic C. difficile strains among long-term care patients in the context of an outbreak of C. difficile-associated disease and evaluated the frequency of skin and environmental contamination. Molecular typing was performed by pulsed-field gel electrophoresis. Logistic regression was used to assess factors associated with asymptomatic carriage, and a sensitive and specific prediction rule was developed to identify high-risk patients. RESULTS Thirty-five (51%) of 68 asymptomatic patients were carriers of toxigenic C. difficile, and 13 (37%) of these patients carried epidemic strains. Compared with noncarriers, asymptomatic carriers had higher percentages of skin (61% vs. 19%; P=.001) and environmental contamination (59% vs. 24%; P=.004). Eighty-seven percent of isolates found in skin samples and 58% of isolates found in environmental samples were identical to concurrent isolates found in stool samples. Spores on the skin of asymptomatic patients were easily transferred to investigators' hands. Previous C. difficile-associated disease (P<.001) and previous antibiotic use (P=.017) were associated with asymptomatic carriage, and the combination of these 2 variables was predictive of asymptomatic carriage (sensitivity, 77%; specificity, 58%; positive predictive value, 66%; negative predictive value, 70%). CONCLUSIONS Our findings suggest that asymptomatic carriers of epidemic and nonepidemic C. difficile strains have the potential to contribute significantly to disease transmission in long-term care facilities. Clinical factors, such as previous C. difficile-associated disease and recent antibiotic use, may be predictive of asymptomatic carriage.
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Affiliation(s)
- Michelle M Riggs
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH 44106, USA
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141
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Muto CA, Blank MK, Marsh JW, Vergis EN, O'Leary MM, Shutt KA, Pasculle AW, Pokrywka M, Garcia JG, Posey K, Roberts TL, Potoski BA, Blank GE, Simmons RL, Veldkamp P, Harrison LH, Paterson DL. Control of an outbreak of infection with the hypervirulent Clostridium difficile BI strain in a university hospital using a comprehensive "bundle" approach. Clin Infect Dis 2007; 45:1266-73. [PMID: 17968819 DOI: 10.1086/522654] [Citation(s) in RCA: 205] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Accepted: 07/06/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In June 2000, the hospital-acquired Clostridium difficile (CD) infection rate in our hospital (University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, PA) increased to 10.4 infections per 1000 hospital discharges (HDs); the annual rate increased from 2.7 infections per 1000 HDs to 7.2 infections per 1000 HDs and was accompanied by an increase in the frequency of severe outcomes. Forty-seven (51%) of 92 HA CD isolates in 2001 were identified as the "epidemic BI strain." A comprehensive CD infection control "bundle" was implemented to control the outbreak of CD infection. METHODS The CD infection control bundle consisted of education, increased and early case finding, expanded infection-control measures, development of a CD infection management team, and antimicrobial management. Process measures, antimicrobial usage, and hospital-acquired CD infection rates were analyzed, and CD isolates were typed. RESULTS The rates of compliance with hand hygiene and isolation were 75% and 68%, respectively. The CD management team evaluated a mean of 31 patients per month (11% were evaluated for moderate or severe disease). Use of antimicrobial therapy associated with increased CD infection risk decreased by 41% during the period 2003-2005 (P<.001). The aggregate rate of CD infection during the period 2001-2006 decreased to 4.8 infections per 1000 HDs (odds ratio, 2.2; 95% confidence interval, 1.4-3.1; P<.001) and by 2006, was 3.0 infections per 1000 HDs, a rate reduction of 71% (odds ratio, 3.5; 95% confidence interval, 2.3-5.4; P<.001). During the period 2000-2001, the proportion of severe CD cases peaked at 9.4% (37 of 393 CD infections were severe); the rate decreased to 3.1% in 2002 and further decreased to 1.0% in 2006--a 78% overall reduction (odds ratio, 20.3; 95% confidence interval, 2.8-148.2; P<.001). In 2005, 13% of CD isolates were type BI (20% were hospital acquired), which represented a significant reduction from 2001 (P<.001). CONCLUSIONS The outbreak of CD infection with the BI strain in our hospital was controlled after implementing a CD infection control "bundle." Early identification, coupled with appropriate control measures, reduces the rate of CD infection and the frequency of adverse events.
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Affiliation(s)
- Carlene A Muto
- Division of Hospital Epidemiology and Infection Control, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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142
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Quinn LK, Chen Y, Herwaldt LA. Infection control policies and practices for Iowa long-term care facility residents with Clostridium difficile infection. Infect Control Hosp Epidemiol 2007; 28:1228-32. [PMID: 17926271 DOI: 10.1086/520747] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Accepted: 06/05/2007] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To identify infection control policies and practices used by Iowa long-term care facilities (LTCFs) for residents with Clostridium difficile infection or C. difficile-associated diarrhea and to assess use of antimicrobial agents. DESIGN Survey. SETTING LTCFs in Iowa that responded between March 25, 2005 (ie, when surveys were mailed), and July 2005. RESULTS Of the 418 LTCFs in Iowa, 263 (62.9%) responded. Most facilities (94.3%) reported that they accept persons known to have C. difficile infection. Few LTCFs reported that clusters of C. difficile infection had been identified. However, only 111 facilities (42.2%) had a protocol to identify residents with C. difficile infection, and most (77.5%) did not test for C. difficile unless a resident had severe diarrhea. Only 58.5% of the facilities placed residents with C. difficile infection in private rooms, and 60.9% cohorted residents infected with C. difficile with other residents with C. difficile colonization or infection. Only 66 facilities (25.1%) have a program to control the use of antimicrobial agents. Staff could use alcohol-based hand gel products after contact with residents known to have C. difficile infection (in 188 facilities [71.5%]) or diarrhea (in 173 [65.8%]). However, the survey did not ask whether the staff used alcohol-based products instead of soap and water. CONCLUSIONS C. difficile is present in Iowa LTCFs, but many C. difficile infections probably remain undiagnosed. Staff in LTCFs should be educated about this organism so that they can implement appropriate testing and preventive strategies.
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Affiliation(s)
- Laura K Quinn
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA 52242, USA
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143
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Valiquette L, Cossette B, Garant MP, Diab H, Pépin J. Impact of a Reduction in the Use of High-Risk Antibiotics on the Course of an Epidemic of Clostridium difficile-Associated Disease Caused by the Hypervirulent NAP1/027 Strain. Clin Infect Dis 2007; 45 Suppl 2:S112-21. [PMID: 17683015 DOI: 10.1086/519258] [Citation(s) in RCA: 259] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
A series of measures were implemented, in a secondary/tertiary-care hospital in Quebec, to control an epidemic of nosocomial Clostridium difficile-associated disease (n-CDAD) caused by a virulent strain; these measures included the development of a nonrestrictive antimicrobial stewardship program. Interrupted time-series analysis was used to evaluate the impact of these measures on n-CDAD incidence. From 2003-2004 to 2005-2006, total and targeted antibiotic consumption, respectively, decreased by 23% and 54%, and the incidence of n-CDAD decreased by 60%. No change in n-CDAD incidence was noted after strengthening of infection control procedures (P=.63), but implementation of the antimicrobial stewardship program was followed by a marked reduction in incidence (P=.007). This suggests that nonrestrictive measures to optimize antibiotic usage can yield exceptional results when physicians are motivated and that such measures should be a mandatory component of n-CDAD control. The inefficacy of infection control measures targeting transmission through hospital personnel might be a result of their implementation late in the epidemic, when the environment was heavily contaminated with spores.
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Affiliation(s)
- Louis Valiquette
- Department of Microbiology and Infectious Diseases, University of Sherbrooke, Sherbrooke, Quebec, Canada.
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144
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Cookson B. Hypervirulent strains of Clostridium difficile. Postgrad Med J 2007; 83:291-5. [PMID: 17488855 PMCID: PMC2600085 DOI: 10.1136/pgmj.2006.056143] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Accepted: 01/16/2007] [Indexed: 12/18/2022]
Abstract
North America has seen increasing numbers of hospitalised patients and others in nursing homes and the community, with more severe Clostridium difficile associated diarrhoea. This is also described in Northern Europe and surveillance systems are being developed or improved to monitor the situation. One strain (ribotype O27) is described in detail and, like other emerging strains, is demonstrating increasing antimicrobial resistance, notably to quinolone antibiotics. However, its association with increased virulence is not straightforward, probably reflecting the interactions with differing patient case mix. There are many subtypes of the strain and more sophisticated typing and virulence assessment systems need to be developed using isolates carefully collected to test different epidemiological hypotheses. There are also environmental factors relating to treatment such as antimicrobials, cytotoxics and proton pump inhibitors. An emerging theme is the importance of aspects of healthcare delivery in contributing to the problem; this includes poorly maintained and cleaned healthcare premises, overcrowded hospitals and increased staffing workloads leading to poor compliance with infection control.
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Affiliation(s)
- Barry Cookson
- Centre for Infections, Health Protection Agency, 61 Colindale Avenue, London, NW9 5HT, UK.
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145
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McFarland LV, Beneda HW, Clarridge JE, Raugi GJ. Implications of the changing face of Clostridium difficile disease for health care practitioners. Am J Infect Control 2007; 35:237-53. [PMID: 17482995 DOI: 10.1016/j.ajic.2006.06.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 06/19/2006] [Accepted: 06/20/2006] [Indexed: 01/19/2023]
Abstract
Recent reported outbreaks of Clostridium difficile-associated disease in Canada have changed the profile of C difficile infections. Historically, C difficile disease was thought of mainly as a nosocomial disease associated with broad-spectrum antibiotics, and the disease was usually not life threatening. The emergence of an epidemic strain, BI/NAP1/027, which produces a binary toxin in addition to the 2 classic C difficile toxins A and B and is resistant to some fluoroquinolones, was associated with large numbers of cases with high rates of mortality. Recently, C difficile has been reported more frequently in nonhospital-based settings, such as community-acquired cases. The C difficile disease is also being reported in populations once considered of low risk (children and young healthy women). In addition, poor response to metronidazole treatment is increasing. Faced with an increasing incidence of C difficile infections and the changing profile of patients who become infected, this paper will reexamine the current concepts on the epidemiology and treatment of C difficile-associated disease, present new hypotheses for risk factors, examine the role of spores in the transmission of C difficile, and provide recommendations that may enhance infection control practices.
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Affiliation(s)
- Lynne V McFarland
- From the Department of Health Services Research and Development, Veterans Administration Puget Sound Health Care System, Seattle, WA 98101, USA.
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146
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Fletcher KR, Cinalli M. Identification, Optimal Management, and Infection Control Measures for Clostridium difficile–Associated Disease in Long-Term Care. Geriatr Nurs 2007; 28:171-81; quiz 182. [PMID: 17561015 DOI: 10.1016/j.gerinurse.2007.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Revised: 02/09/2007] [Accepted: 02/17/2007] [Indexed: 10/23/2022]
Abstract
Residents of long-term care facilities are at an increased risk of exposure to Clostridium difficile and become more susceptible to infection after receiving antimicrobial therapy. An increasing number and more severe cases of C. difficile-associated disease (CDAD) have been reported over the last few years and have been linked to the emergence of a new, more virulent strain of C. difficile. These serious cases of disease have also been associated with a more atypical clinical presentation and have prompted the need for an improved means of early recognition and identification performed by the nursing staff. This article reviews the pathogenesis and risk factors for CDAD, changing epidemiology of CDAD, and characteristics of the newly identified strain. Also reviewed are the role of nursing in the identification of patients with CDAD; optimal management of CDAD; infection control strategies; and education of health care professionals, residents, and visitors in the long-term care setting.
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147
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Bouza E, Burillo A, Muñoz P. Antimicrobial therapy of Clostridium difficile-associated diarrhea. Med Clin North Am 2006; 90:1141-63. [PMID: 17116441 DOI: 10.1016/j.mcna.2006.07.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Clostridium difficile-associated diarrhea (CDAD) is the most common etiologically-defined cause of hospital-acquired diarrhea. Caused by the toxins of certain strains of C difficile, CDAD represents a growing concern, with epidemic outbreaks in some hospitals where very aggressive and difficult-to-treat strains have recently been found. Incidence of CDAD varies ordinarily between 1 to 10 in every 1,000 admissions. Evidence shows that CDAD increases morbidity, length of stay, and costs. This article described the clinical manifestations of CDAD, related risk factors, considerations for confirming CDAD, antimicrobial and non-antimicrobial treatment of CDAD, and issues related to relapses. The article concludes with a discussion of recent epidemic outbreaks involving CDAD.
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Affiliation(s)
- Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Dr. Esquerdo 46, 28007 Madrid, Spain
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148
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Antimicrobial Functionality of Healthcare Textiles: Current needs, Options, and Characterization of N halamine-Based Finishes. ACTA ACUST UNITED AC 2006. [DOI: 10.1108/rjta-10-04-2006-b001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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149
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Laffan AM, Bellantoni MF, Greenough WB, Zenilman JM. Burden of Clostridium difficile-associated diarrhea in a long-term care facility. J Am Geriatr Soc 2006; 54:1068-73. [PMID: 16866677 DOI: 10.1111/j.1532-5415.2006.00768.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To describe the incidence and prevalence of Clostridium difficile-associated diarrhea (CDAD) in a long-term care facility (LTCF). DESIGN Retrospective review of CDAD cases between July 2001 and December 2003. SETTING Two hundred two-bed LTCF affiliated with an academic medical center in Baltimore, Maryland. PARTICIPANTS All residents of the facility during July 2001 to December 2003. MEASUREMENTS Clinical and laboratory-confirmed cases of CDAD. RESULTS Incidence of CDAD ranged from 0 to 2.62 cases per 1,000 resident days. The highest rates were observed in residents of subacute units, whereas incidence was much lower on traditional nursing home units. Prevalence of CDAD at admission was greater on units (subacute and rehabilitative) where the majority of patients were admitted from hospital settings than on those where the majority of patients were admitted from the community (nursing home units). Recurrent disease occurred in 21.7% of patients with CDAD. CONCLUSION CDAD remains a problem in the long-term care setting, and importation from the acute care setting accounts for a large proportion of the C. difficile seen LTCFs. As the population continues to age, issues of disease and infection in long-term care are expected to increase. New prevention and control strategies are needed to control the spread of CDAD in LTCFs.
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Affiliation(s)
- Alison M Laffan
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 21224, USA.
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150
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McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis 2006. [PMID: 16704777 PMCID: PMC3291455 DOI: 10.3201/eid1203.051064] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clinicians should be aware of the increasing risk of C. difficile–associated disease and make efforts to control its transmission. US hospital discharges for which Clostridium difficile–associated disease (CDAD) was listed as any diagnosis doubled from 82,000 (95% confidence interval [CI] 71,000–94,000) or 31/100,000 population in 1996 to 178,000 (95% CI 151,000–205,000) or 61/100,000 in 2003; this increase was significant between 2000 and 2003 (slope of linear trend 9.48; 95% CI 6.16–12.80, p = 0.01). The overall rate during this period was severalfold higher in persons >65 years of age (228/100,000) than in the age group with the next highest rate, 45–64 years (40/100,000; p<0.001). CDAD appears to be increasing rapidly in the United States and is disproportionately affecting older persons. Clinicians should be aware of the increasing risk for CDAD and make efforts to control transmission of C. difficile and prevent disease.
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