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Pires D, Prendki V, Renzi G, Fankhauser C, Sauvan V, Huttner B, Schrenzel J, Harbarth S. Low frequency of asymptomatic carriage of toxigenic Clostridium difficile in an acute care geriatric hospital: prospective cohort study in Switzerland. Antimicrob Resist Infect Control 2016; 5:24. [PMID: 27280019 PMCID: PMC4898375 DOI: 10.1186/s13756-016-0123-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/01/2016] [Indexed: 12/12/2022] Open
Abstract
Background The role of asymptomatic carriers of toxigenic Clostridium difficile (TCD) in nosocomial cross-transmission remains debatable. Moreover, its relevance in the elderly has been sparsely studied. Objectives To assess asymptomatic TCD carriage in an acute care geriatric population. Methods We performed a prospective cohort study at the 296-bed geriatric hospital of the Geneva University Hospitals. We consecutively recruited all patients admitted to two 15-bed acute-care wards. Patients with C. difficile infection (CDI) or diarrhoea at admission were excluded. First bowel movement after admission and every two weeks thereafter were sampled. C. difficile toxin B gene was identified using real-time polymerase chain-reaction (BD MAXTMCdiff). Asymptomatic TCD carriage was defined by the presence of the C. difficile toxin B gene without diarrhoea. Results A total of 102 patients were admitted between March and June 2015. Two patients were excluded. Among the 100 patients included in the study, 63 were hospitalized and 1 had CDI in the previous year, and 36 were exposed to systemic antibiotics within 90 days prior to admission. Overall, 199 stool samples were collected (median 2 per patient, IQR 1-3). Asymptomatic TCD carriage was identified in two patients (2 %). Conclusions We found a low prevalence of asymptomatic TCD carriage in a geriatric population frequently exposed to antibiotics and healthcare. Our findings suggest that asymptomatic TCD carriage might contribute only marginally to nosocomial TCD cross-transmission in our and similar healthcare settings.
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Affiliation(s)
- Daniela Pires
- Infection Control Program, Geneva University Hospitals, 4, rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland ; Department of Infectious Diseases, Centro Hospitalar Lisboa Norte and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Virginie Prendki
- Department of Geriatrics, Geneva University Hospitals, Geneva, Switzerland
| | - Gesuele Renzi
- Central Laboratory of Bacteriology, Geneva University Hospitals, Geneva, Switzerland
| | - Carolina Fankhauser
- Infection Control Program, Geneva University Hospitals, 4, rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland
| | - Valerie Sauvan
- Infection Control Program, Geneva University Hospitals, 4, rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland
| | - Benedikt Huttner
- Infection Control Program, Geneva University Hospitals, 4, rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland ; Department of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland ; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jacques Schrenzel
- Central Laboratory of Bacteriology, Geneva University Hospitals, Geneva, Switzerland ; Department of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland ; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals, 4, rue Gabrielle Perret-Gentil, 1211 Geneva, Switzerland ; Department of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland ; Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Furuya-Kanamori L, Marquess J, Yakob L, Riley TV, Paterson DL, Foster NF, Huber CA, Clements ACA. Asymptomatic Clostridium difficile colonization: epidemiology and clinical implications. BMC Infect Dis 2015; 15:516. [PMID: 26573915 PMCID: PMC4647607 DOI: 10.1186/s12879-015-1258-4] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/31/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The epidemiology of Clostridium difficile infection (CDI) has changed over the past decades with the emergence of highly virulent strains. The role of asymptomatic C. difficile colonization as part of the clinical spectrum of CDI is complex because many risk factors are common to both disease and asymptomatic states. In this article, we review the role of asymptomatic C. difficile colonization in the progression to symptomatic CDI, describe the epidemiology of asymptomatic C. difficile colonization, assess the effectiveness of screening and intensive infection control practices for patients at risk of asymptomatic C. difficile colonization, and discuss the implications for clinical practice. METHODS A narrative review was performed in PubMed for articles published from January 1980 to February 2015 using search terms 'Clostridium difficile' and 'colonization' or 'colonisation' or 'carriage'. RESULTS There is no clear definition for asymptomatic CDI and the terms carriage and colonization are often used interchangeably. The prevalence of asymptomatic C. difficile colonization varies depending on a number of host, pathogen, and environmental factors; current estimates of asymptomatic colonization may be underestimated as stool culture is not practical in a clinical setting. CONCLUSIONS Asymptomatic C. difficile colonization presents challenging concepts in the overall picture of this disease and its management. Individuals who are colonized by the organism may acquire protection from progression to disease, however they also have the potential to contribute to transmission in healthcare settings.
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Affiliation(s)
- Luis Furuya-Kanamori
- Research School of Population Health, The Australian National University, Building 62 Mills Road, Canberra, ACT 2601, Australia.
| | - John Marquess
- School of Population Health, The University of Queensland, Herston, QLD, Australia.
- Queensland Department of Health, Communicable Diseases Unit, Herston, QLD, Australia.
| | - Laith Yakob
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK.
| | - Thomas V Riley
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western Australia, Nedlands, WA, Australia.
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia.
| | - David L Paterson
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, Australia.
| | - Niki F Foster
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia.
| | - Charlotte A Huber
- The University of Queensland, UQ Centre for Clinical Research, Herston, QLD, Australia.
| | - Archie C A Clements
- Research School of Population Health, The Australian National University, Building 62 Mills Road, Canberra, ACT 2601, Australia.
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Schoevaerdts D, Verroken A, Huang TD, Swine C, Glupczynski Y. Asymptomatic Colonization byClostridium difficilein Older Adults Admitted to a Geriatric Unit: A Prospective Cohort Study. J Am Geriatr Soc 2011; 59:2179-81. [DOI: 10.1111/j.1532-5415.2011.03685.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Alexia Verroken
- Department of Infectiology and Microbiology; University Medical Center Mont-Godinne; Yvoir; Belgium
| | - Te-Din Huang
- Department of Infectiology and Microbiology; University Medical Center Mont-Godinne; Yvoir; Belgium
| | | | - Youri Glupczynski
- Department of Infectiology and Microbiology; University Medical Center Mont-Godinne; Yvoir; Belgium
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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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Ryan J, Murphy C, Twomey C, Paul Ross R, Rea MC, MacSharry J, Sheil B, Shanahan F. Asymptomatic carriage of Clostridium difficile in an Irish continuing care institution for the elderly: prevalence and characteristics. Ir J Med Sci 2009; 179:245-50. [DOI: 10.1007/s11845-009-0361-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 05/02/2009] [Indexed: 11/29/2022]
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Simor AE, Bradley SF, Strausbaugh LJ, Crossley K, Nicolle LE. Clostridium difficile in long-term-care facilities for the elderly. Infect Control Hosp Epidemiol 2002; 23:696-703. [PMID: 12452300 DOI: 10.1086/501997] [Citation(s) in RCA: 181] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Antimicrobial agents are among the most frequently prescribed medications in long-term-care facilities (LTCFs). Therefore, it is not surprising that Clostridium difficile colonization and C. difficile-associated diarrhea (CDAD) occur commonly in elderly LTCF residents. C. difficile has been identified as the most common cause of non-epidemic acute diarrheal illness in nursing homes, and outbreaks of CDAD in LTCFs have also been recognized. This position paper reviews the epidemiology and clinical features of CDAD in elderly residents of LTCFs and, using available evidence, provides recommendations for the management of C. difficile in this setting.
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Affiliation(s)
- Andrew E Simor
- Department of Microbiology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
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Caputo GM, Weitekamp MR, Bacon AE, Whitener C. Clostridium difficile infection: a common clinical problem for the general internist. J Gen Intern Med 1994; 9:528-33. [PMID: 7996299 DOI: 10.1007/bf02599229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Considering the current wide use of antimicrobial agents, the general internist is commonly faced with the patient at risk for diarrhea due to C. difficile. The diagnosis should be considered for any patient with diarrhea who has received any type of antibiotic therapy in the preceding 4-6 weeks. Symptoms may range from a minor bout of diarrhea to fulminant and fatal colitis. Diagnosis usually requires demonstration of the toxin in stool; culture of the organism and fiberoptic endoscopy may play an adjunctive role in selected clinical settings. The ultimate goal in the treatment for C. difficile infection is to repopulate the normal colonic flora in the most efficacious manner. Minimally symptomatic patients may respond to discontinuing the offending antimicrobial agent or using nonspecific binding agents. Oral vancomycin continues to be the "gold standard" for specific treatment, while metronidazole therapy is considered the first-line agent for individuals with milder infection. Oral bacitracin shows promise, though large studies are lacking. Patients with multiple relapses of C. difficile diarrhea can be treated with prolonged courses of vancomycin or a combination of vancomycin and rifampin. Intensive care unit patients who are NPO have few therapeutic options besides intravenous administration of metronidazole and oral administration of vancomycin via clamped nasogastric tube. Preventive efforts are directed at cautious use of antibiotics and the use of vinyl gloves when caring for patients with known infection.
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Affiliation(s)
- G M Caputo
- Department of Medicine, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey 17033-2390
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Cartmill TD, Panigrahi H, Worsley MA, McCann DC, Nice CN, Keith E. Management and control of a large outbreak of diarrhoea due to Clostridium difficile. J Hosp Infect 1994; 27:1-15. [PMID: 7916358 DOI: 10.1016/0195-6701(94)90063-9] [Citation(s) in RCA: 107] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In the six-month period 1 November 1991 to 1 May 1992 175 patients developed diarrhoea due to Clostridium difficile in three hospitals in Manchester, UK. Most patients (90%) were over 60 years old and had been admitted to acute geriatric or medical wards with other illnesses. Infection is thought to have contributed to 17 deaths. Twenty-two patients relapsed clinically after antibiotic treatment. The outbreak began in one ward and affected 15 patients and two nurses. During the following months cases occurred on 34 wards. The pattern of spread suggested that a ward index case was followed by several secondary cases. Pyrolysis mass spectrometry showed that 79% of isolates of C. difficile belong to a single cluster and this putative outbreak strain also extensively colonizes the hospital environment. It was also responsible for a smaller outbreak in 1991 and many 'sporadic' cases in our hospitals before then. An outbreak control team was convened at an early stage and expert opinion co-opted. Infection control measures included: intensive education of staff; increased vigilance; strict enteric precautions; cohort nursing in a designated ward; rigorous cleaning procedures including emptying and 'deep' cleaning of wards where several cases had occurred; restriction of staff and patient movement; and restriction of antibiotic use. Subsequent to these measures there has been a substantial and sustained decrease in the number of new cases.
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Affiliation(s)
- T D Cartmill
- Department of Microbiology, North Manchester General Hospital, Crumpsall, UK
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Rudensky B, Rosner S, Sonnenblick M, van Dijk Y, Shapira E, Isaacsohn M. The prevalence and nosocomial acquisition of Clostridium difficile in elderly hospitalized patients. Postgrad Med J 1993; 69:45-7. [PMID: 8446550 PMCID: PMC2399593 DOI: 10.1136/pgmj.69.807.45] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Rectal swabs obtained from 10 of 49 chronic-care geriatric patients were positive for Clostridium difficile, for a prevalence rate of 20.4%. Simultaneous sampling of 29 patients in an acute geriatric ward revealed four colonized patients, for a prevalence rate of 13.7%. A prospective study of C. difficile colonization in 100 consecutive patients admitted to an acute geriatric ward was carried out. All patients were sampled upon admission and biweekly during hospitalization. Two patients (2%) were positive on admission, and 12 of the 98 initially negative patients became colonized, representing a nosocomial acquisition rate of 12.2%. A major determinant for C. difficile colonization in asymptomatic patients appears to be length of hospitalization. Previous antibiotic administration was not found to be a significant factor.
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Affiliation(s)
- B Rudensky
- Department of Clinical Microbiology, Shaare Zedek Medical Center, Jerusalem, Israel
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