Co-morbidities as predictors of mortality in Clostridium difficile infection and derivation of the ARC predictive score

"Primum, non nocere": The Epidemiology of Toxigenic Clostridioides difficile Strains in the Antibiotic Era-Insights from a Prospective Study at a Regional Infectious Diseases Hospital in Eastern Europe

Clostridioides difficile infection (CDI), though identified nearly five decades ago, still remains a major challenge, being associated with significant mortality rates. The strains classified as hypervirulent, notably 027/NAP1/BI, have garnered substantial attention from researchers and clinicians due to their direct correlation with the severity of the disease. Our study aims to elucidate the significance of toxigenic Clostridioides difficile (CD) strains in the clinical and therapeutic aspects of managing patients diagnosed with CDI. We conducted a single-center prospective study, including patients with CDI from north-eastern Romania. We subsequently conducted molecular biology testing to ascertain the prevalence of the presumptive 027/NAP1/BI strain within aforementioned geographic region. The patients were systematically compared and assessed both clinically and biologically, employing standardized and comparative methodologies. The study enrolled fifty patients with CDI admitted between January 2020 and June 2020. Among the investigated patients, 43 (86%) exhibited infection with toxigenic CD strains positive for toxin B genes (tcdB), binary toxin genes (cdtA and cdtB), and deletion 117 in regulatory genes (tcdC), while the remaining 7 (14%) tested negative for binary toxin genes (cdtA and cdtB) and deletion 117 in tcdC. The presence of the presumptive 027/NAP1/BI strains was linked to a higher recurrence rate (35.56%, p = 0.025), cardiovascular comorbidities (65.1% vs. 14.2%, p = 0.016), and vancomycin treatment (55.8% vs. 14.3%, p = 0.049). The findings of our investigation revealed an elevated incidence of colitis attributed to presumptive 027/NAP1/BI. Despite the prevalence of the presumptive 027 strain and its associated heightened inflammation among the patients studied, no significant differences were observed regarding the clinical course or mortality outcomes.

Clostridioides difficile Infection: A Clinical Review of Pathogenesis, Clinical Considerations, and Treatment Strategies

BACKGROUND

Clostridioides difficile infection (CDI) is a common nosocomial infection. Risk factors for developing CDI include prior hospitalization, being older than 65 years old, antibiotic use, and chronic disease. It is linked with diarrhea and colitis and can vary in severity. It is a major cause of increased morbidity and mortality among hospitalized patients. However, community-acquired CDI is also increasing. Proper diagnosis and determination of severity are crucial for the treatment of CDI. Depending on how severe the CDI is, the patient may endorse different symptoms and physical exam findings. The severity of CDI will determine how aggressively it is treated. Management and treatment: Laboratory studies can be helpful in the diagnosis of CDI. In this regard, common labs include complete blood count, stool assays, and, in certain cases, radiography and endoscopy. Mild-to-moderate colitis is treated with antibiotics, but severe colitis requires a different approach, which may include surgery. Several alternative therapies for CDI exist and have shown promising results. This review will touch upon these therapies, which include fecal transplants, intravenous immunoglobulin, and the use of cholestyramine and tigecycline.

CONCLUSION

Prevention of CDI can be achieved by proper hygiene, vaccinations, and detecting the infection early. Proper hygiene is indeed noted to be one of the best ways to prevent CDI in the hospital setting. Overprescribing antibiotics is also another huge reason why CDI occurs. Proper prescription of antibiotics can also help reduce the chances of acquiring CDI.

Clostridioides difficile infection recurrence in the VINC at hospitals: a prospective observational cohort study

Background: The 2016 cumulative incidence of Clostridioides difficile infection (CDI) in Spain was reported by the European Center for Disease Control to be above the mean of other European countries. The aim of this multicenter prospective observational cohort study was to examine the risk factors that determine 90-day CDI recurrence in Catalonia, Spain. Methods: The study included 558 consecutive adults admitted to hospital who had a symptomatic, first positive CDI diagnosis. Sociodemographic, clinical and epidemiological variables were recorded. The primary outcome was 90-day CDI recurrence. Results: In this Catalan population, having received more than one course of antibiotics in the 30 days prior to CDI diagnosis (odds ratio: 2.459; 95% CI: 1.195–5.060; p = 0.015) and active chemotherapy (odds ratio: 4.859; 95% CI: 1.495–15.792; p = 0.009) are significant predictors of 90-day CDI recurrence. Conclusion: The identification of independent risk factors of 90-day CDI recurrence will enable the optimization of preventive measures in at-risk populations.

Early Prognostic Stratification of Clostridioides difficile Infection in the Emergency Department: The Role of Age and Comorbidities

Clostridioides difficile infection (CDI) represents a significant cause of morbidity and mortality, mainly in older and frail subjects. Early identification of outcome predictors, starting from emergency department (ED) admission, could help to improve their management. In a retrospective single-center study on patients accessing the ED for diarrhea and hospitalized with a diagnosis of CDI infection, the patients’ clinical history, presenting symptoms, vital signs, and laboratory exams at ED admission were recorded. Quick sequential organ failure assessments (qSOFA) were conducted and Charlson’s comorbidity indices (CCI) were calculated. The primary outcomes were represented by all-cause in-hospital death and the occurrence of major cumulative complications. Univariate and multivariate Cox regression analyses were performed to establish predictive risk factors for poor outcomes. Out of 450 patients, aged > 81 years, dyspnea at ED admission, creatinine > 2.5 mg/dL, white blood cell count > 13.31 × 109/L, and albumin < 30 µmol/L were independently associated with in-hospital death and major complications (except for low albumin). Both in-hospital death and major complications were not associated with multimorbidity. In patients with CDI, the risk of in-hospital death and major complications could be effectively predicted upon ED admission. Patients in their 8th decade have an increased risk independent of comorbidities.

External Validation and Comparison of Clostridioides difficile Severity Scoring Systems

BACKGROUND

Many models have been developed to predict severe outcomes from Clostridioides difficile infection (CDI). These models are usually developed at a single institution and largely are not externally validated. Our aim in this study was to validate previously published risk scores in a multicenter cohort of patients with CDI.

METHODS

This was a retrospective study on 4 inpatient cohorts with CDI from 3 distinct sites: the universities of Michigan (2010-2012 and 2016), Chicago (2012), and Wisconsin (2012). The primary composite outcome was admission to an intensive care unit, colectomy, and/or death attributed to CDI within 30 days of positive testing. Both within each cohort and combined across all cohorts, published CDI severity scores were assessed and compared to each other and the Infectious Diseases Society of America (IDSA) guideline definitions of severe and fulminant CDI.

RESULTS

A total of 3646 patients were included for analysis. Including the 2 IDSA guideline definitions, 14 scores were assessed. Performance of scores varied within each cohort and in the combined set (mean area under the receiver operator characteristic curve [AuROC], 0.61; range, 0.53-0.66). Only half of the scores had performance at or better than IDSA severe and fulminant definitions (AuROCs of 0.64 and 0.63, respectively). Most of the scoring systems had more false than true positives in the combined set (mean, 81.5%; range, 0%-91.5%).

CONCLUSIONS

No published CDI severity score showed stable, good predictive ability for adverse outcomes across multiple cohorts/institutions or in a combined multicenter cohort.

Risk Factors of Severe Clostridioides difficile Infection; Sequential Organ Failure Assessment Score, Antibiotics, and Ribotypes

We aimed to determine whether the Sequential Organ Failure Assessment (SOFA) score predicts the prognosis of patients with Clostridioides difficile infection (CDI). In addition, the association between the type of antibiotic used and PCR ribotypes was analyzed. We conducted a propensity score (PS)-matched study and machine learning analysis using clinical data from all adult patients with confirmed CDI in three South Korean hospitals. A total of 5,337 adult patients with CDI were included in this study, and 828 (15.5%) were classified as having severe CDI. The top variables selected by the machine learning models were maximum body temperature, platelet count, eosinophil count, oxygen saturation, Glasgow Coma Scale, serum albumin, and respiratory rate. After propensity score-matching, the SOFA score, white blood cell (WBC) count, serum albumin level, and ventilator use were significantly associated with severe CDI (P < 0.001 for all). The log-rank test of SOFA score ≥ 4 significantly differentiated severe CDI patients from the non-severe group. The use of fluoroquinolone was more related to CDI patients with ribotype 018 strains than to ribotype 014/020 (P < 0.001). Even after controlling for other variables using propensity score matching analysis, we found that the SOFA score was a clinical predictor of severe CDI. We also demonstrated that the use of fluoroquinolones in hospital settings could be associated with the PCR ribotype in patients with CDI.

European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults

SCOPE

In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults.

METHODS AND QUESTIONS

Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure.

RECOMMENDATIONS

Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.

Prognostic factors for severe and recurrent Clostridioides difficile infection: a systematic review

OBJECTIVES

Clostridioides difficile infection (CDI), its subsequent recurrences (rCDIs), and severe CDI (sCDI) provide a significant burden for both patients and the healthcare system. Identifying patients diagnosed with initial CDI who are at increased risk of developing sCDI/rCDI could lead to more cost-effective therapeutic choices. In this systematic review we aimed to identify clinical prognostic factors associated with an increased risk of developing sCDI or rCDI.

METHODS

PubMed, Embase, Emcare, Web of Science and COCHRANE Library databases were searched from database inception through March, 2021. The study eligibility criteria were cohort and case-control studies. Participants were patients ≥18 years old diagnosed with CDI, in which clinical or laboratory factors were analysed to predict sCDI/rCDI. Risk of bias was assessed by using the Quality in Prognostic Research (QUIPS) tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool modified for prognostic studies. Study selection was performed by two independent reviewers. Overview tables of prognostic factors were constructed to assess the number of studies and the respective effect direction and statistical significance of an association.

RESULTS

136 studies were included for final analysis. Greater age and the presence of multiple comorbidities were prognostic factors for sCDI. Identified risk factors for rCDI were greater age, healthcare-associated CDI, prior hospitalization, proton pump inhibitors (PPIs) started during or after CDI diagnosis, and previous rCDI.

CONCLUSIONS

Prognostic factors for sCDI and rCDI could aid clinicians to make treatment decisions based on risk stratification. We suggest that future studies use standardized definitions for sCDI/rCDI and systematically collect and report the risk factors assessed in this review, to allow for meaningful meta-analysis of risk factors using data of high-quality trials.

Clinical characteristics associated with the severity of Clostridium [Clostridioides] difficile infection in a tertiary teaching hospital from Mexico

Background

Clostridium difficile infection (CDI) is a leading cause of healthcare-associated diarrhea worldwide. In this study, risk factors associated with the development of severe-complicated and recurrent outcomes in CDI patients in different age groups, including the non-elderly, were assessed in a third-level hospital.

Methods

CDI cases were detected by clinical data and polymerase-chain-reaction (PCR). Clinical, demographic, epidemiological, and microbiological risk factors for CDI were evaluated.

Results

During the study period, 248 out of 805 patients with nosocomial diarrhea were diagnosed with CDI and the majority were severe-complicated cases (87.90%). Female gender (OR 3.19, 95% CI 1.19–8.55, p = 0.02) and lymphoma (OR 3.95, 95% CI 1.03–15.13, p = 0.04) were risk factors for severe-complicated CDI. Mature adulthood (51–60 years) (OR 5.80, 95% CI 1.56–21.62, p = 0.01), previous rifampicin use (OR 7.44, 95% CI 2.10–26.44, p = 0.00), and neoplasm (solid malignant neoplasm or hematological malignancies) (OR 4.12, 95% CI 1.01–16.83, p = 0.04) were risk factors for recurrent infection. Autoimmune disorders (OR 6.62, CI 95% 1.26–34.73, p = 0.02), leukemia (OR 4.97, 95% CI 1.05–23.58, p = 0.04), lymphoma (OR 3.79, 95% CI 1.03–12.07, p = 0.04) and previous colistin treatment (OR 4.97, 95% CI 1.05–23.58, p = 0.04) were risk factors for 30-day mortality.

Conclusion

Newly identified risk factors for recurrent CDI were rifampicin treatment and age between 51 and 60 years; colistin treatment was identified as a risk factor for 30-day mortality. Previously identified risk factors for severe-complicated CDI were confirmed, but with a major impact on non-elderly patients.

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

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

Assessment of Kidney Injury as a Severity Criteria for Clostridioides Difficile Infection

BACKGROUND

The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) revised their Clostridioides difficile infection (CDI) severity classification criteria in 2017 to include an absolute serum creatinine (SCr) value above a threshold (≥1.5 mg/dL) rather than a relative increase from baseline (≥1.5 times the premorbid level). To date, how to best define kidney injury as a CDI disease severity marker has not been validated to assess severe outcomes associated with CDI.

METHODS

This multicenter cohort study included adult hospitalized patients with CDI. Patients were assessed for the presence of acute kidney injury (AKI), chronic kidney disease (CKD), and CDI severity using the 2010 and 2017 IDSA/SHEA CDI guidelines. Primary outcome was all-cause inpatient mortality.

RESULTS

The final study cohort consisted of 770 CDI episodes from 705 unique patients aged 65 ± 17 years (female, 54%; CKD, 36.5%; AKI, 29.6%). Eighty-two episodes (10.6%) showed discordant severity classification results due to the inclusion of more patients with preexisting CKD in the severe disease category using an absolute SCr threshold criterion. The absolute SCr criterion better correlated with all-cause mortality (odds ratio [OR], 4.04; 95% confidence interval [CI], 1.76-9.28; P = .001) than the relative increase in SCr (OR, 1.34; 95% CI, 0.62-2.89; P = .46). This corresponded to an increased likelihood of the 2017 CDI severity classification criteria to predict mortality (OR, 5.33; 95% CI, 1.81-15.72; P = .002) compared with the 2010 criteria (OR, 2.71; 95% CI, 1.16-6.32; P = .02).

CONCLUSIONS

Our findings support the 2017 IDSA/SHEA CDI severity classification criteria of a single pretreatment SCr in future CDI guideline updates.

Development and validation of a clinical risk calculator for mortality after colectomy for fulminant Clostridium difficile colitis

BACKGROUND

Clostridium difficile colitis is an increasingly important cause of morbidity and mortality. Fulminant C. difficile colitis (FCDC) is a severe form of the colitis driven by a significant systemic inflammatory response, and managed with a total abdominal colectomy. Despite surgery, postoperative mortality rates remain high. The aim of this study was to develop a bedside calculator to predict the risk of 30-day postoperative mortality for patients with FCDC.

METHODS

After institutional review board approval, the American College of Surgeons National Surgical Quality Improvement Program database (2005-2015) was used to include adult patients who underwent emergency surgery for FCDC. A priori preoperative predictors of mortality were selected from the literature: age, immunosuppression, preoperative shock, intubation, and laboratory values. The predictive accuracy of different logistic regression models was measured by calculating the area under the receiver-operating characteristic curve. A cohort of 124 patients from Québec was used to validate the developed mortality calculator.

RESULTS

A total of 557 patients met the inclusion criteria, and the overall mortality was 44%. After developing the calculator, no statistically significant differences were found in comparison with the American College of Surgeons National Surgical Quality Improvement Program probability of mortality available in the database (area under the receiver operating curve, 75.61 vs. 75.14; p = 0.79). External validation with the cohort of patients from Quebec showed an area under the curve of 74.0% (95% confidence interval, 65.0-82.9).

CONCLUSION

A clinically applicable calculator using preoperative variables to predict postoperative mortality for patients with FCDC was developed and externally validated. This calculator may help guide preoperative decision making.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level III.

The Clinical Burden of Clostridioides difficile in Ontario, Canada

Background

To understand the clinical burden of Clostridioides difficile infection (CDI), we analyzed health outcome data from Ontario, Canada for CDI associated with and manifested in acute care hospitals (ACH), long-term care facilities (LTCF), the community, or ACH-associated with community-onset.

Methods

We performed a retrospective analysis using individual-level data from Ontario databases (April 1, 2005 to March 31, 2015), identifying CDI cases ≥18 years requiring hospitalization, and stratifying into cohorts based on association and onset location. Cohort members were matched to controls on demographics and medical conditions at onset, for outcomes including 30- and 180-day all-cause mortality and rehospitalization.

Results

We stratified 22 617 individuals hospitalized with CDI during the study period: 13 152 (58.1%) ACH-associated/ACH-onset, 7116 (31.5%) community-associated/community-onset, 1847 (8.2%) ACH-associated/community-onset, and 502 (2.2%) LTCF-associated/LTCF-onset. Compared with controls, unadjusted 30-day rehospitalization rates were significantly higher (P < .0001) for ACH-associated/ACH-onset CDI (9.5% vs 0.4%), LTCF-associated/LTCF-onset (7.2% vs 1.1%), community-associated/community-onset (7.8% vs 0.8%), and ACH-associated/community-onset (10.9% vs 0.7%). One hundred eighty-day mortality rates were higher in the community-associated/community-onset and the LTCF-associated/LTCF-onset cohorts than controls: 66.3% vs 12.3% (P < .0001) and 30.9% vs 3.1% (P < .0001), respectively. All differences remained significant after adjusting for patient factors.

Conclusions

Clostridioides difficile infection is associated with higher rates of 30-day rehospitalization compared with controls. In addition, mortality rates within 180-days of hospital discharge are significantly higher for community-associated/community-onset and LTCF-associated/LTCF-onset CDI cohorts than controls. Clostridioides difficile infection warrants increased prevention and monitoring efforts.

Validation of the SHEA/IDSA severity criteria to predict poor outcomes among inpatients and outpatients with Clostridioides difficile infection

OBJECTIVE

To determine whether the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Clostridioides difficile infection (CDI) severity criteria adequately predicts poor outcomes.

DESIGN

Retrospective validation study.

SETTING AND PARTICIPANTS

Patients with CDI in the Veterans’ Affairs Health System from January 1, 2006, to December 31, 2016.

METHODS

For the 2010 criteria, patients with leukocytosis or a serum creatinine (SCr) value ≥1.5 times the baseline were classified as severe. For the 2018 criteria, patients with leukocytosis or a SCr value ≥1.5 mg/dL were classified as severe. Poor outcomes were defined as hospital or intensive care admission within 7 days of diagnosis, colectomy within 14 days, or 30-day all-cause mortality; they were modeled as a function of the 2010 and 2018 criteria separately using logistic regression.

RESULTS

We analyzed data from 86,112 episodes of CDI. Severity was unclassifiable in a large proportion of episodes diagnosed in subacute care (2010, 58.8%; 2018, 49.2%). Sensitivity ranged from 0.48 for subacute care using 2010 criteria to 0.73 for acute care using 2018 criteria. Areas under the curve were poor and similar (0.60 for subacute care and 0.57 for acute care) for both versions, but negative predictive values were >0.80.

CONCLUSIONS

Model performances across care settings and criteria versions were generally poor but had reasonably high negative predictive value. Many patients in the subacute-care setting, an increasing fraction of CDI cases, could not be classified. More work is needed to develop criteria to identify patients at risk of poor outcomes.

External validation of clinical prediction rules for complications and mortality following Clostridioides difficile infection

Background

Several clinical prediction rules (CPRs) for complications and mortality of Clostridioides difficile infection (CDI) have been developed but only a few have gone through external validation, and none is widely recommended in clinical practice.

Methods

CPRs were identified through a systematic review. We included studies that predicted severe or complicated CDI (cCDI) and mortality, reported at least an internal validation step, and for which data were available with minimal modifications. Data from a multicenter prospective cohort of 1380 adults with confirmed CDI were used for external validation. In this cohort, cCDI occurred in 8% of the patients and 30-day all-cause mortality occurred in 12%. The performance of each tool was assessed using individual outcomes, with the same cut-offs and standard parameters.

Results

Seven CPRs were assessed. Three predictive scores for cCDI showed low sensitivity (25–61%) and positive predictive value (PPV; 9–31%), but moderate specificity (54–90%) and negative predictive value (NPV; 82–95%). One model [using age, white blood cell count (WBC), narcotic use, antacids use, and creatinine ratio > 1.5× the normal level as covariates] showed a probability of 25% of cCDI at the optimal cut-off point with 36% sensitivity and 84% specificity. Two scores for mortality had low sensitivity (4–55%) and PPV (25–31%), and moderate specificity (71–78%) and NPV (87–92%). One predictive model for 30-day all-cause mortality [Charlson comorbidity index, WBC, blood urea nitrogen (BUN), diagnosis in ICU, and delirium] showed an AUC-ROC of 0.74. All other CPRs showed lower AUC values (0.63–0.69). Errors in calibration ranged from 12%- 27%.

Conclusions

Included CPRs showed moderate performance for clinical use in a large validation cohort with a majority of patients infected with ribotype 027 strains and a low rate of cCDI and mortality. These data show that better CPRs need to be developed and validated.

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

Background

Current guidelines have unsatisfied performance in predicting severe outcomes after Clostridium difficile infection (CDI). Our objectives were to develop a risk prediction model for 30-day mortality and to examine its performance among inpatients with CDI.

Methods

This retrospective cohort study was conducted at China Medical University Hospital, a 2111-bed tertiary medical center in central Taiwan. We included adult inpatients who had a first positive C. difficile culture or toxin assay and had diarrhea as the study population. The main exposure of interest was the biochemical profiles of white blood cell count, serum creatinine (SCr), estimated glomerular filtration rate, blood urea nitrogen (BUN), serum albumin, and glucose. The primary outcome was the 30-day all-cause mortality and the secondary outcome was the length of stay in the intensive care units (ICU) following CDI. A multivariable Cox model and a logistic regression model were developed using clinically relevant and statistically significant variables for 30-day mortality and for length of ICU stay, respectively. A risk scoring system was established by standardizing the coefficients. We compared the performance of our models and the guidelines.

Results

Of 401 patients, 23.4% died within 30 days. In the multivariable model, malignancy (hazard ratio [HR] = 1.95), ≥ 1.5-fold rise in SCr (HR = 2.27), BUN-to-SCr ratio > 20 (HR = 2.04), and increased glucose (≥ 193 vs < 142 mg/dL, HR = 2.18) were significant predictors of 30-day mortality. For patients who survived the first 30 days of CDI, BUN-to-SCr ratio > 20 (Odds ratio [OR] = 4.01) was the only significant predictor for prolonged (> 9 days) length of ICU stay following CDI. The Harrell's c statistic of our Cox model for 30-day mortality (0.727) was significantly superior to those of SHEA-IDSA 2010 (0.645), SHEA-IDSA 2018 (0.591), and ECSMID (0.650). Similarly, the conventional c statistic of our logistic regression model for prolonged ICU stay (0.737) was significantly superior to that of the guidelines (SHEA-IDSA 2010, c = 0.600; SHEA-IDSA 2018, c = 0.634; ESCMID, c = 0.645). Our risk prediction scoring system for 30-day mortality correctly reclassified 20.7, 32.1, and 47.9% of patients, respectively.

Conclusions

Our model that included novel biomarkers of BUN-to-SCr ratio and glucose have a higher predictive performance of 30-day mortality and prolonged ICU stay following CDI than do the guidelines.

Acute Clostridioides difficile Infection in Hospitalized Persons Aged 75 and Older: 30-Day Prognosis and Risk Factors for Mortality

OBJECTIVES

To assess the 30-day mortality predictive markers in the oldest patients with Clostridioides difficile infection (CDI) and to analyze the accuracy of the European severity risk markers in this population.

DESIGN

Observational prospective multicenter cohort study conducted by the French Infectious Diseases Society and Geriatrics Society networks. An electronic questionnaire was sent to members of both societies regarding their participation. Each investigator used an online survey to gather the data.

SETTING AND PARTICIPANTS

Patients aged ≥75 years hospitalized in French geriatric or infectious wards with confirmed diagnosis of CDI between March 1, 2016 and May 1, 2017.

METHODS

Clinical and laboratory parameters included medical history and comorbidities with the Cumulative Illness Rating Scale (CIRS). Criteria increasing the risk of severe disease were recorded as listed in the European guidelines. Therapeutic management, recurrence, and mortality rates were assessed at day 30 after diagnosis.

RESULTS

Included patients numbered 247; mean age was 87.2 years (SD 5.4). Most of the CDI incidences (66.4%) were health care-associated infections, with 81% diagnosed within 30 days of hospitalization; CIRS mean score was 16.6 (SD 6.6). Markers of severity ≥3 included 97 patients (39.3%). Metronidazole was the main initial treatment (51.0%). C difficile infection in the older adult was associated with a 30-day mortality of 12.6%. Multivariate analysis showed that baseline CIRS score [hazard ratio (HR) 1.06 per 1-point increase, 95% confidence interval (CI) 1.00-1.12] and evidence of cardiac, respiratory, or renal decompensation (HR 3.04, 95% CI 1.40-6.59) were significantly associated with mortality.

CONCLUSIONS AND IMPLICATIONS

European severity markers are adequate in the oldest old. Organ failure and comorbidities appeared to be the main markers of prognosis, and these should raise the awareness of practitioners. Although antibiotic treatment was not predictive of mortality, our results point out the lack of adherence to current guidelines in this population.

High delayed mortality after the first episode of Clostridium difficile infection

Clostridium difficile infection (CDI) is characterized by a high delayed and unrelated mortality. Predicting delayed mortality in CDI patients could allow the implementation of interventions that could reduce these events. A prospective multicentric study was carried out to investigate prognostic factors associated with mortality. It was based on a cohort (July 2015 to February 2016) of 295 patients presenting with CDI. Logistic regression was used and the model was calibrated using the Hosmer-Lemeshow test. The mortality rate at 75 days in our series was 18%. Age (>65 years), comorbidity (defined by heart failure, diabetes mellitus with any organ lesion, renal failure, active neoplasia or immunosuppression) and fecal incontinence at clinical presentation were associated with delayed (75-day) mortality. When present, each of the aforementioned variables added one point to the score. Mortalities with 0, 1, 2 and 3 points were 0%, 9.4%, 18.5% and 38.2%, respectively. The area under the ROC curve was 0.743, and the Hosmer-Lemeshow goodness-of-fit test p value was 0.875. Therefore, the prediction of high delayed mortality in CDI patients by our scoring system could promote measures for increasing survival in suitable cases.

2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients

In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

Acute kidney injury impact on inpatient mortality in Clostridium difficile infection: A national propensity-matched study

BACKGROUND AND AIM

Acute kidney injury (AKI) is used as a marker of severity in Clostridium difficile infection (CDI) patients. We estimated the true effect of AKI in inpatient mortality of CDI patients, as there are no large-scale, population-based, propensity-matched studies evaluating AKI's effect in this patient cohort.

METHODS

A retrospective observational study utilizing the National Inpatient Sample from years 2003 to 2012, including all adults with CDI, excluding cases missing data on age, inpatient mortality or gender. Trends and CDI-related complications as mortality predictors were assessed using survey-weighted multivariable regression. We estimated AKI's independent effect by propensity-matching, post-stratifying by chronic kidney disease status, allowing for multiple comorbidity adjustment.

RESULTS

A total of 2 859 599 patients with CDI were included, of which 896 122 (31.3%) had principal diagnosis of CDI. AKI prevalence was 22%. Mortality rate was 8.4%, while among AKI patients was higher (18.2%). In multivariable regression, AKI was associated with higher mortality (odds ratio [OR] = 3.16, 95% confidence interval [CI]: 3.02-3.30; P < 0.001), while after propensity matching, AKI increased mortality by 86% (OR = 1.86, 95% CI: 1.79-1.94; P < 0.001). CDI incidence increased by 1.8, together with the rate of AKI (12.6% in 2003 to 28.8% in 2012, P-trend < 0.001). Despite increasing hospitalizations, mortality over the study period decreased to 7.2% (2012) from 9.0% (2003); P-trend < 0.001.

CONCLUSION

Hospital admissions of patients with CDI and concomitant AKI are increasing, but their inpatient mortality has improved over the study period. AKI is a significant contributor to mortality, independently of other comorbidities, complications, and hospital characteristics, emphasizing the need for early diagnosis and aggressive management in such patients.

The effect of concomitant use of systemic antibiotics in patients with Clostridium difficile infection receiving metronidazole therapy

Management of Clostridium difficile infection (CDI) involves discontinuation of the offending antibiotic agent as soon as possible. However, the ongoing infection does not allow discontinuation of the offending antibiotic. We aimed to retrospectively investigate the predictors of treatment failure and impact of the concomitant use of systemic antibiotics in patients receiving metronidazole therapy. This study was conducted among patients hospitalised at a second care academic hospital from January 2013 to December 2014. Eligible patients were identified by reviewing stool toxin enzyme immunoassay results for C. difficile. Diarrhoea was defined as the passage of at least three loose or watery stools within 24 h. Among 314 patients with CDI receiving metronidazole therapy, 62 (19.7%) showed treatment failure and 105 (33.4%) received concomitant antibiotics. Underlying dialysis, fever >38.3 °C, low median serum albumin levels and concomitant use of antibiotics were independent predictors of treatment failure in patients with CDI receiving metronidazole therapy. The concomitant use of antibiotics increased the rates of treatment failure and 30-day mortality in patients receiving metronidazole therapy. These results suggest that metronidazole should be used in mild cases of CDI only after discontinuation of the offending antibiotics.

Molecular epidemiology of Clostridium difficile infection in a Brazilian cancer hospital

Clostridium difficile is a Gram-positive spore forming anaerobic bacterium and the main cause of healthcare-associated diarrhea. This study aimed to perform the phenotypic characterization and molecular typing of Clostridium difficile isolates among patients at a cancer hospital in Brazil. During 18 months, 48 diarrheic fecal samples were collected, of these 48% were positive in either one or both of the performed tests: detection of toxins A/B and culture. Clostridium difficile was recovered from four samples (17%). All strains carried toxin A and B genes, and the isolates belonged to PCR-ribotype 014/020, PGFE-type NAP4 and toxinotype XVIII. On the other hand, one isolate belonged to a novel PCR-ribotype, and PFGE-type, likewise to toxinotype IXb. The isolates showed susceptibility to metronidazole, vancomycin and moxifloxacin, and were resistant to ciprofloxacin. Finally, the findings indicate high positivity between the samples tested, suggesting an expressive importance of this infection, including detection of a novel ribotype/PFGE-type of Clostridium difficile, and show for the first time the detection of community-associated Clostridium difficile infection (CA-CDI) in these patients in Northeast Brazil. These data emphasize the importance to a better understanding of the epidemiological situation of this infection in Brazilian hospitals.

External Validation of Three Prediction Tools for Patients at Risk of a Complicated Course of Clostridium difficile Infection: Disappointing in an Outbreak Setting

OBJECTIVE Estimating the risk of a complicated course of Clostridium difficile infection (CDI) might help doctors guide treatment. We aimed to validate 3 published prediction models: Hensgens (2014), Na (2015), and Welfare (2011). METHODS The validation cohort comprised 148 patients diagnosed with CDI between May 2013 and March 2014. During this period, 70 endemic cases of CDI occurred as well as 78 cases of CDI related to an outbreak of C. difficile ribotype 027. Model calibration and discrimination were assessed for the 3 prediction rules. RESULTS A complicated course (ie, death, colectomy, or ICU admission due to CDI) was observed in 31 patients (21%), and 23 patients (16%) died within 30 days of CDI diagnosis. The performance of all 3 prediction models was poor when applied to the total validation cohort with an estimated area under the curve (AUC) of 0.68 for the Hensgens model, 0.54 for the Na model, and 0.61 for the Welfare model. For those patients diagnosed with CDI due to non-outbreak strains, the prediction model developed by Hensgens performed the best, with an AUC of 0.78. CONCLUSION All 3 prediction models performed poorly when using our total cohort, which included CDI cases from an outbreak as well as endemic cases. The prediction model of Hensgens performed relatively well for patients diagnosed with CDI due to non-outbreak strains, and this model may be useful in endemic settings. Infect Control Hosp Epidemiol 2017;38:897-905.

Clinical, immunological and microbiological predictors of poor outcome in Clostridium difficile infection

BACKGROUND

Clostridium difficile infection (CDI) causes increased morbidity and mortality. Clinical data cannot clearly predict poor CDI outcome. Data on the value of microbiological predictors is scarce.

OBJECTIVE

To identify early predictors of poor outcome of CDI.

METHODS

We prospectively included patients with CDI aged >2years. Clinical, immunological (Toxin B IgG/Ig A and Toxin A IgG/Ig A), microbiological factors (bacterial load, toxin quantification, sporulation, germination, and metronidazole susceptibility) were evaluated to identify early independent predictors of poor outcome.

RESULTS

We identified 204 cases of CDI; outcome was poor in 22.1%. Advanced age, presence of comorbidities, leukocytosis and high toxigenic C. difficile load were independently associated with poor outcome. We could not demonstrate this correlation for antitoxin antibodies.

CONCLUSION

We identified high bacterial load as a microbiological predictor of poor outcome. We propose this factor to be included in combined clinical and microbiological prediction rules of poor outcome in CDI.

The efficacy of fidaxomicin in the treatment of Clostridium difficile infection in a real-world clinical setting: a Spanish multi-centre retrospective cohort

The objective of this study was to evaluate the efficacy and safety of fidaxomicin in the real-life clinical setting. This was a retrospective cohort of patients with Clostridium difficile infection (CDI) treated with fidaxomicin in 20 Spanish hospitals between July 2013 and July 2014. Clinical cure, 30-day recurrence, 30-day mortality, sustained cure, and factors associated with the failure to achieve sustained cure were analyzed. Of the 72 patients in the cohort 41 (56.9 %) had a fatal underlying disease. There were 44 (61.1 %) recurrent episodes and 26 cases (36.1 %) with a history of multiple recurrences. Most episodes were severe (26, 36 %) or severe-complicated (14, 19.4 %). Clinical cure rate was 90.3 %, recurrence rate was 16.7 % and three patients (4.2 %) died during the follow-up period. Sustained cure was achieved in 52 cases (72.2 %). Adverse events were reported in five cases (6.9 %). Factors associated with the lack of sustained cure were cardiovascular comorbidity (OR 11.4; 95 %CI 1.9-67.8), acute kidney failure (OR 7.4; 95 %CI 1.3-43.1), concomitant systemic antibiotic treatment (OR 6.2; 95 %CI 1.1-36.8), and C-reactive protein value at diagnosis (OR 1.2 for each 1 mg/dl increase; 95 %CI 1.03-1.3). Fidaxomicin is an effective and well tolerable treatment for severe CDI and for cases with elevated recurrence risk.

A Comparison of Current Guidelines of Five International Societies on Clostridium difficile Infection Management

Clostridium difficile infection (CDI) is increasingly recognized as an emerging healthcare problem of elevated importance. Prevention and treatment strategies are constantly evolving along with the apperance of new scientific evidence and novel treatment methods, which is well-reflected in the differences among consecutive international guidelines. In this article, we summarize and compare current guidelines of five international medical societies on CDI management, and discuss some of the controversial and currently unresolved aspects which should be addressed by future research.

Epidemiology, Diagnosis, and Management of Clostridium difficile Infection in Patients with Inflammatory Bowel Disease

Clostridium difficile infection (CDI) is a major source of morbidity and mortality for the U.S. health care system and frequently complicates the course of inflammatory bowel disease (IBD). Patients with IBD are more likely to be colonized with C. difficile and develop active infection than the general population. They are also more likely to have severe CDI and develop subsequent complications such as IBD flare, colectomy, or death. Even after successful initial treatment and recovery, recurrent CDI is common. Management of CDI in IBD is fraught with diagnostic and therapeutic challenges because the clinical presentations of CDI and IBD flare have considerable overlap. Fecal microbiota transplantation can be successful in curing recurrent CDI when other treatments have failed, but may also trigger IBD flare and this warrants caution. New experimental treatments including vaccines, monoclonal antibodies, and nontoxigenic strains of C. difficile offer promise but are not yet available for clinicians. A better understanding of the complex relationship between the gut microbiota, CDI, and IBD is needed.

Toxin B PCR cycle threshold as a predictor of poor outcome of Clostridium difficile infection: a derivation and validation cohort study

OBJECTIVES

Prediction of patients with poor outcome is necessary in order to plan the proper management of Clostridium difficile infection (CDI); however, clinical criteria are insufficient. In a previous study, we observed that high toxigenic C. difficile cfu stool counts at diagnosis were associated with a poor outcome. Our objective was to investigate the role of the PCR toxin B amplification cycle threshold (Ct) in the prediction of CDI poor outcome and to derive and validate a high-risk prediction rule using this marker.

METHODS

We prospectively included patients with CDI (derivation cohort, January 2013 to June 2014; and validation cohort, December 2014 to May 2015), who were followed for at least 2 months after their last episode/recurrence. All samples were tested with Xpert™ C. difficile.

RESULTS

For the derivation cohort (n = 129) toxin B Ct was independently associated with poor outcome (P < 0.001). The receiver operating characteristic (ROC) curve yielded an AUC of 0.816. Using a cut-off of <23.5 cycles for high risk of poor outcome, the diagnostic accuracy was 81.4%, the sensitivity was 46.5% (95% CI 32.5-61.1) and the specificity was 98.8% (95% CI 93.7-99.8). For the validation cohort (n = 170), the diagnostic accuracy was 81.8%, the sensitivity was 88.4% (95% CI 75.5-94.9) and the specificity was 79.5% (95% CI 71.7-85.6). The ROC curve yielded an AUC of 0.857.

CONCLUSIONS

Low toxin B Ct values from samples collected at the initial moment of diagnosis appears to be a strong marker for poor outcome. This available test may identify, at an early stage, patients who are at higher risk of a poor outcome CDI.

Chronic kidney disease and end-stage renal disease are risk factors for poor outcomes of Clostridium difficile infection: a systematic review and meta-analysis

BACKGROUND

The objective of this systematic review and meta-analysis was to assess the clinical outcomes of Clostridium difficile infection (CDI) in patients with chronic kidney diseases (CKD) and end-stage renal disease (ESRD).

METHODS

A literature search was performed from inception through February 2015. Studies that reported relative risks, odds ratios or hazard ratios comparing the clinical outcomes of CDI in patients with CKD or ESRD and those without CKD or ESRD were included. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method.

RESULTS

Nineteen studies (a case-control and 18 cohort studies) with 116,875 patients assessing clinical outcomes of CDI were included in the meta-analysis. Pooled RR of severe or complicated CDI in CKD patients was 1.51 (95% CI: 1.00-2.28). The risk of recurrent CDI is significant higher in patients with a pooled RR of 2.73 (95% CI: 1.36-5.47). The pooled RR of mortality risk of CDI in patients with CKD, ESRD and CKD or ESRD were 1.76 (95% CI: 1.26-2.47), 1.58 (1.37-1.83) and 1.76 (1.32-2.34) respectively.

CONCLUSION

This meta-analysis demonstrates poor outcomes of CDI including severe and recurrent CDI in CKD patients. History of CKD and ESRD are both associated with increased mortality risk in patients with CDI.

WSES guidelines for management of Clostridium difficile infection in surgical patients

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.

Clostridium difficile ribotype 027: relationship to age, detectability of toxins A or B in stool with rapid testing, severe infection, and mortality

BACKGROUND

Clostridium difficile infection (CDI) can cause severe disease and death, especially in older adults. A better understanding of risk factors for adverse outcomes is needed. This study tests the hypotheses that infection with specific ribotypes and presence of stool toxins independently associate with severity and constructs predictive models of adverse outcomes.

METHODS

Cases of non-recurrent CDI were prospectively included after positive stool tests for toxins A and/or B by enzyme immunoassay (EIA) or tcdB by polymerase chain reaction. Outcomes included severe CDI (intensive care unit admission, colectomy, or death attributable to CDI within 30 days of diagnosis) and 30-day all-cause mortality. Adjusted models were developed to test hypotheses and predict outcomes.

RESULTS

In total, 1144 cases were included. The toxin EIA was positive in 37.2% and 35.6% of patients were of age >65 years. One of the 137 unique ribotypes was ribotype 027 (16.2%). Detectable stool toxin did not associate with outcomes. Adjusting for covariates, including age, Ribotype 027 was a significant predictor of severe CDI (90 cases; odds ratio [OR], 1.73; 95% confidence interval [CI], 1.03-2.89; P = .037) and mortality (89 cases; OR, 2.02; 95% CI, 1.19-3.43; P = .009). Concurrent antibiotic use associated with both outcomes. Both multivariable predictive models had excellent performance (area under the curve >0.8).

CONCLUSIONS

Detection of stool toxin A and/or B by EIA does not predict severe CDI or mortality. Infection with ribotype 027 independently predicts severe CDI and mortality. Use of concurrent antibiotics is a potentially modifiable risk factor for severe CDI.

Clostridium difficile in western Romania: unfavourable outcome predictors in a hospital for infectious diseases

BACKGROUND

The recent emergence of Clostridium difficile infections has included this condition among top nosocomial infections, due to its incidence, complications and important fatality, as well as to significant economic costs.

METHODS

A prospective surveillance study of Clostridium difficile enterocolitis cases was performed in "Victor Babeş" Infectious Diseases Hospital in Timişoara (Romania) between 01.01.2013 - 30.06.2014, to estimate the incidence and to investigate the risk factors for unfavourable outcome and relapse. Dichotomous variables were compared by the chi-square test or Fisher exact test and the Mann-Whitney U test was used for continuous variables. Risk factors for unfavourable outcome/recurrence were investigated by logistic regression.

RESULTS

210 patients who experienced 219 episodes of infection with Clostridium difficile were identified, which gives an incidence per hospital of 20.57/15.70 to 1,000 discharged patients in 2013/2014 or 17.73/14.04 to 10,000 patient-days. In 162 patients (77.14%) the evolution was favourable while in 48 (22.86%) the outcome was unfavourable. In 42 patients (20.00%) recurrence of symptoms was identified. The multivariate analysis by logistic regression identified the ATLAS score (OR = 4.97, 95% CI = 2.12 to 11.66, p <0.001), age (OR = 1.12, 95% CI = 1.00 to 1.25, p = 0.046), and the number of antibiotics after episode onset (OR = 2.692, 95% CI = 1.01 to 7.17, p = 0.047) as predictors of an unfavourable evolution, while the number of hospitalization days (OR = 1.10, 95% CI = 1.03 to 1.16, p = 0.0015) was associated with recurrence of symptoms.

CONCLUSIONS

The high incidence identified in our study is explained by the endemic character of these infections in some hospitals in Timişoara, released in late 2012, and the fact that "Victor Babeş" Hospital is the only one in our area that provides treatment in all suspected or confirmed cases of this condition requiring hospitalization. The study identified the ATLAS score, age, and the number of antibiotics after episode onset as predictors of unfavourable evolution, while the number of days of hospitalization was associated with the recurrence of symptoms.

Clostridium difficile infection: prevention, treatment, and surgical management

Clostridium difficile is increasing in both incidence and severity. Although metronidazole and vancomycin remain the gold standard for medical management, and surgical colectomy the gold standard for surgical management, new treatment alternatives, including the creation of a diverting loop ileostomy along with colonic lavage and vancomycin enemas, are being investigated that may lead to changes in the current treatment algorithms. The most exciting development in the treatment options for C difficile infection, however, is likely to be novel immunologic agents, which hold the potential to reduce the incidence, mortality, and costs associated with C difficile.

European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection

In 2009 the first European Society of Clinical Microbiology and Infection (ESCMID) treatment guidance document for Clostridium difficile infection (CDI) was published. The guideline has been applied widely in clinical practice. In this document an update and review on the comparative effectiveness of the currently available treatment modalities of CDI is given, thereby providing evidence-based recommendations on this issue. A computerized literature search was carried out to investigate randomized and non-randomized trials investigating the effect of an intervention on the clinical outcome of CDI. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The ESCMID and an international team of experts from 11 European countries supported the process. To improve clinical guidance in the treatment of CDI, recommendations are specified for various patient groups, e.g. initial non-severe disease, severe CDI, first recurrence or risk for recurrent disease, multiple recurrences and treatment of CDI when oral administration is not possible. Treatment options that are reviewed include: antibiotics, toxin-binding resins and polymers, immunotherapy, probiotics, and faecal or bacterial intestinal transplantation. Except for very mild CDI that is clearly induced by antibiotic usage antibiotic treatment is advised. The main antibiotics that are recommended are metronidazole, vancomycin and fidaxomicin. Faecal transplantation is strongly recommended for multiple recurrent CDI. In case of perforation of the colon and/or systemic inflammation and deteriorating clinical condition despite antibiotic therapy, total abdominal colectomy or diverting loop ileostomy combined with colonic lavage is recommended.

Variations in virulence and molecular biology among emerging strains of Clostridium difficile

Clostridium difficile is a Gram-positive, spore-forming organism which infects and colonizes the large intestine, produces potent toxins, triggers inflammation, and causes significant systemic complications. Treating C. difficile infection (CDI) has always been difficult, because the disease is both caused and resolved by antibiotic treatment. For three and a half decades, C. difficile has presented a treatment challenge to clinicians, and the situation took a turn for the worse about 10 years ago. An increase in epidemic outbreaks related to CDI was first noticed around 2003, and these outbreaks correlated with a sudden increase in the mortality rate of this illness. Further studies discovered that these changes in CDI epidemiology were associated with the rapid emergence of hypervirulent strains of C. difficile, now collectively referred to as NAP1/BI/027 strains. The discovery of new epidemic strains of C. difficile has provided a unique opportunity for retrospective and prospective studies that have sought to understand how these strains have essentially replaced more historical strains as a major cause of CDI. Moreover, detailed studies on the pathogenesis of NAP1/BI/027 strains are leading to new hypotheses on how this emerging strain causes severe disease and is more commonly associated with epidemics. In this review, we provide an overview of CDI, discuss critical mechanisms of C. difficile virulence, and explain how differences in virulence-associated factors between historical and newly emerging strains might explain the hypervirulence exhibited by this pathogen during the past decade.

[Clostridium difficile infections in Spanish Internal Medicine departments during the period 2005-2010: the burden of the disease]

INTRODUCTION

Clostridium Difficile infection (CDI) is increasing in Spain. A review is presented of this infection in order to evaluate the burden of the disease in this country.

MATERIAL

An analytical retrospective and descriptive study was conducted by analyzing the Minimum Basic Data Set of patients admitted to Internal Medicine Departments and with and without CDI between the years 2005-2010. Clinical and demographical variables were compared.

RESULTS

Mean age was 75.5 years (SD 15.4), 54.9% were women and mean stay was 22.2 days (SD 24.8). The Cost [(€ 5,001 (SD 4,985) vs [€ 3,934 (SD 2,738)] and diagnostic complexity [2.04 (SD 2.62) vs [1.67 (SD 1.47)] were also different. Mortality for all causes was 12.5% vs 9.8%. Death risk showed a 30% increase (odds ratio 1.30, 95% confidence interval;1.21-1.39) and readmission rate was 30.4% vs 13.5%. Distribution of cases showed season variations (more cases in winter), and annual incidence increased during the study period. Comorbidities associated to increased risk of acquiring CDI were: anemia, human immunodeficiency virus, dementia, malnutrition, chronic renal failure, and living in a nursing home.

CONCLUSION

The results showed a clear negative impact of CDI on hospital admissions. A trend towards progression in its incidence without changes in mortality or readmission rates was observed, in common with the rest of Europe and the Western World.

Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories

Clostridium difficile is a formidable nosocomial and community-acquired pathogen, causing clinical presentations ranging from asymptomatic colonization to self-limiting diarrhea to toxic megacolon and fulminant colitis. Since the early 2000s, the incidence of C. difficile disease has increased dramatically, and this is thought to be due to the emergence of new strain types. For many years, the mainstay of C. difficile disease diagnosis was enzyme immunoassays for detection of the C. difficile toxin(s), although it is now generally accepted that these assays lack sensitivity. A number of molecular assays are commercially available for the detection of C. difficile. This review covers the history and biology of C. difficile and provides an in-depth discussion of the laboratory methods used for the diagnosis of C. difficile infection (CDI). In addition, strain typing methods for C. difficile and the evolving epidemiology of colonization and infection with this organism are discussed. Finally, considerations for diagnosing C. difficile disease in special patient populations, such as children, oncology patients, transplant patients, and patients with inflammatory bowel disease, are described. As detection of C. difficile in clinical specimens does not always equate with disease, the diagnosis of C. difficile infection continues to be a challenge for both laboratories and clinicians.

Predicting a complicated course of Clostridium difficile infection at the bedside

Clostridium difficile infections (CDIs) are a common cause of antibiotic-associated diarrhoea and associated with CDI-related mortality in c. 10%. To date, there is no prediction model in use that guides clinicians to identify patients at high risk for complicated CDI. From 2006 to 2009, nine Dutch hospitals included hospitalized CDI patients in a prospective cohort. Potential predictors of a complicated course (ICU admission, colectomy or death due to CDI) were evaluated in uni- and multivariate logistic regression. A score was constructed that was internally validated by bootstrapping. Furthermore, a pilot external validation was performed. Twelve per cent of 395 CDI patients had a complicated course within 30 days after diagnosis. Age (≥85 years, OR 4.96; 50-84 years, 1.83), admission due to diarrhoea (OR 3.27), diagnosis at the ICU department (OR 7.03), recent abdominal surgery (OR 0.23) and hypotension (OR 3.25) were independent predictors of a complicated course. These variables were used to construct a prediction model. A score subsequently classified patients into high risk (39% with a complicated course), intermediate (16%), low (5%) or virtually no risk of experiencing a complicated course. The score performed well after internal validation (AUC 0.78) and a pilot external validation among 139 patients showed similar good performance (AUC 0.73). We present an easy-to-use, clinically useful risk score that is capable of categorizing CDI patients according to their outcome. Because classification is available at diagnosis, it could have major implications for treatment choice.

Poor functional status as a risk factor for severe Clostridium difficile infection in hospitalized older adults

OBJECTIVES

To determine the role of impaired functional status as a risk factor for severe Clostridium difficile infection (CDI) in older adults.

DESIGN

Prospective cohort study.

SETTING

University of Michigan Health System, a 930-bed tertiary care hospital.

PARTICIPANTS

Hospitalized individuals with CDI aged 50 and older.

MEASUREMENTS

Demographic and clinical characteristics and a composite outcome, CDI severity score: fever (>38°C), acute organ dysfunction, white blood cell count greater than 15,000/μL, lack of response to therapy, intensive care unit admission, need for colectomy, or death from CDI. Preadmission functional status was assessed according to ability to perform activities of daily living (ADLs); participants were assigned to an ADL class (independent, some assistance, full assistance). Secondary outcomes included length of stay, 90-day mortality and readmission, and CDI recurrence.

RESULTS

Ninety hospitalized individuals with CDI were identified (mean age 66.6 ± 10.2); 58 (64.4%) had severe CDI as measured according to a positive severity score. At baseline, 25 (27.8%) required assistance with ADLs. On univariate analysis, ADL class of full assistance was associated with a positive severity score (odds ratio (OR) = 7, 95% confidence interval (CI) = 1.83-26.79, P = .004). In a multivariable model including age, ADL class, congestive heart failure, diabetes mellitus, depression, weighted Charlson-Deyo comorbidity score, immunosuppression, prior CDI, and proton pump inhibitor use, an ADL class of full assistance retained its association with a positive severity score (OR = 8.1, 95% CI = 1.24-52.95, P = .03). ADL class was not associated with secondary outcomes.

CONCLUSION

In this cohort of hospitalized older adults, impaired functional status was an independent risk factor for severe CDI.

Resolution of Clostridium difficile–Associated Diarrhea in Patients With Cancer Treated With Fidaxomicin or Vancomycin

Purpose

Patients with cancer are at increased risk for Clostridium difficile–associated diarrhea (CDAD). Little is known about treatment response.

Patients and Methods

Two double-blind trials randomly allocated 1,105 patients with CDAD to fidaxomicin or vancomycin treatment (modified intent-to-treat [mITT]), and 183 of these had cancer. Univariate and multivariate post hoc analyses compared effects of treatment and patient characteristics on cure, recurrence, and sustained response after 4 weeks. Time to resolution of diarrhea (TTROD) was also evaluated.

Results

Patients with cancer had a lower cure rate and longer TTROD than patients without cancer. Recurrence rates were similar. Cure was more likely with fidaxomicin than vancomycin (odds ratio [OR] 2.0; P = .065), recurrence was less likely (OR = 0.37; P = .018), and sustained response more frequent (OR = 2.56; P = .003). Under vancomycin, median TTROD was longer in patients with cancer than in those without (123 v 58 hours; log-rank P < .001). With fidaxomicin, median TTROD was not significantly affected by presence of cancer (74 v 54 hours; log-rank P = .145). In the full mITT population, age, hypoalbuminemia, and cancer were inversely associated with clinical cure by multivariate analysis. Study treatment with vancomycin was a significant predictor of recurrence (P < .001). Within the cancer population, low albumin was negatively and fidaxomicin was positively associated with improved cure.

Conclusion

For patients with cancer, fidaxomicin treatment was superior to vancomycin, resulting in higher cure and sustained response rates, shorter TTROD, and fewer recurrences.

Acute kidney injury is an independent marker of severity in Clostridium difficile infection: a nationwide survey

GOALS

To examine clinical outcomes in hospitalized Clostridium difficile infection (CDI) patients with acute kidney injury (AKI) using the National Hospital Discharge Survey for 2005 to 2009.

BACKGROUND

CDI can cause serious complications in hospitalized adults. On the basis of expert opinion, guidelines recommend AKI as a marker of severe CDI, but this has not been extensively validated.

MATERIALS AND METHODS

CDI and AKI patients were identified using International Classification of Diseases 9th edition codes. Weighted data analyses were performed to provide national estimates and compare outcomes in patients with AKI and CDI to CDI patients without AKI.

RESULTS

There were an estimated 1,261,712 patients with CDI identified with a median age of 75 years; 59.2% were female and 17.5% developed AKI. On multiple variable analysis, after adjusting for age, sex, and comorbid conditions, AKI was independently associated with length of hospital stay increase by 1.9 days, risk of colectomy with an odds ratio (OR) of 1.35, all-cause in-hospital mortality (OR, 2.76), and dismissal to a care facility (OR, 1.43), all P<0.0001.

CONCLUSIONS

These data support prior consensus opinion that AKI is an independent marker associated with adverse outcomes in CDI and provides key prognostic information.

Effect of ribotype on all-cause mortality following Clostridium difficile infection

BACKGROUND

Clostridium difficile infection (CDI) is significantly associated with subsequent all-cause mortality. Although a number of studies have investigated mortality associated with CDI, few have compared all-cause mortality between ribotypes.

AIM

We aimed to estimate all-cause mortality following CDI and to investigate the relationship between mortality, ribotype and other available variables.

METHODS

We undertook a retrospective cohort study. All patients with toxin-positive CDI in North East England between July 2009 and June 2011 were matched to death registration data. Differences in all-cause 30-day case fatality were explored using Poisson regression with robust error variances. For survival analysis, an accelerated failure time model with generalized gamma distribution was chosen.

FINDINGS

In total, 1426 patients were included. All-cause case fatality was 10.2%, 16.4%, 25.7% and 38.1% at 7, 14, 30 and 90 days respectively. In multivariate analysis, ribotype 027 (risk ratio: 1.34; 95% confidence interval: 1.02-1.75) and ribotype 015 (0.46; 0.26-0.82) were significantly associated with higher and lower all-cause 30-day case fatality rates, respectively. In survival analysis, only ribotype 015 had significantly lower predicted mortality (P = 0.008). Patients whose infection was hospital-acquired had significantly higher predicted mortality (P < 0.001).

CONCLUSION

This is the first population-based study of comparative mortality between multiple ribotypes. Our study identified a high rate of all-cause mortality following CDI. We found evidence of variability in mortality between ribotypes in this cohort with mortality significantly higher for ribotype 027 at 30 days following diagnosis and significantly lower for ribotype 015.

Impact of intensive infection control team activities on the acquisition of methicillin-resistant Staphylococcus aureus, drug-resistant Pseudomonas aeruginosa and the incidence of Clostridium difficile-associated disease

The transmission of multidrug-resistant organisms (MDROs) is an emerging problem in acute healthcare facilities. To reduce this transmission, we introduced intensive infection control team (ICT) activities and investigated the impact of their introduction. This study was conducted at a single teaching hospital from 1 April 2010 to 31 March 2012. During the intervention period, all carbapenem use was monitored by the ICT, and doctors using carbapenems inappropriately were individually instructed. Information related to patients with newly identified MDROs was provided daily to the ICT and instructions on the appropriate infection control measures for MDROs were given immediately with continuous monitoring. The medical records of newly hospitalized patients were reviewed daily to check previous microbiological results and infection control intervention by the ICT was also performed for patients with a previous history of MDROs. Compared with the pre-intervention period, the antimicrobial usage density of carbapenems decreased significantly (28.5 vs. 17.8 defined daily doses/1000 inpatient days; p < 0.001) and the frequency of use of sanitary items, especially the use of aprons, increased significantly (710 vs 1854 pieces/1000 inpatient days; p < 0.001). The number of cases with hospital-acquired MRSA (0.66 vs. 0.29 cases/1000 inpatient days; p < 0.001), hospital-acquired drug-resistant Pseudomonas aeruginosa (0.23 vs. 0.06 cases/1000 inpatient days; p = 0.006) and nosocomial Clostridium difficile-associated disease (0.47 vs. 0.11 cases/1000 inpatient days; p < 0.001) decreased significantly during the intervention period. Our study showed that proactive and continuous ICT interventions were effective for reduction of MDRO transmission.

Procalcitonin levels associate with severity of Clostridium difficile infection

Objective

Clostridium difficile infection (CDI) is a major cause of morbidity and biomarkers that predict severity of illness are needed. Procalcitonin (PCT), a serum biomarker with specificity for bacterial infections, has been little studied in CDI. We hypothesized that PCT associated with CDI severity.

Design

Serum PCT levels were measured for 69 cases of CDI. Chart review was performed to evaluate the presence of severity markers and concurrent acute bacterial infection (CABI). We defined the binary variables clinical score as having fever (T >38°C), acute organ dysfunction (AOD), and/or WBC >15,000 cells/mm³ and expanded score, which included the clinical score plus the following: ICU admission, no response to therapy, colectomy, and/or death.

Results

In univariate analysis log₁₀ PCT associated with clinical score (OR 3.13, 95% CI 1.69–5.81, P<.001) and expanded score (OR 3.33, 95% CI 1.77–6.23, P<.001). In a multivariable model including the covariates log₁₀ PCT, enzyme immunoassay for toxin A/B, ribotype 027, age, weighted Charlson-Deyo comorbidity index, CABI, and extended care facility residence, log₁₀ PCT associated with clinical score (OR 3.09, 95% CI 1.5–6.35, P = .002) and expanded score (OR 3.06, 95% CI 1.49–6.26, P = .002). PCT >0.2 ng/mL was 81% sensitive/73% specific for a positive clinical score and had a negative predictive value of 90%.

Conclusion

An elevated PCT level associated with the presence of CDI severity markers and CDI was unlikely to be severe with a serum PCT level below 0.2 ng/mL. The extent to which PCT changes during CDI therapy or predicts recurrent CDI remains to be quantified.