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Yu H, Alfred T, Nguyen JL, Zhou J, Olsen MA. Incidence, Attributable Mortality, and Healthcare and Out-of-Pocket Costs of Clostridioides difficile Infection in US Medicare Advantage Enrollees. Clin Infect Dis 2022; 76:e1476-e1483. [PMID: 35686435 PMCID: PMC9907506 DOI: 10.1093/cid/ciac467] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND US attributable Clostridioides difficile infection (CDI) mortality and cost data are primarily from Medicare fee-for-service populations, and little is known about Medicare Advantage Enrollees (MAEs). This study evaluated CDI incidence among MAEs from 2012 to 2019 and determined attributable mortality and costs by comparing MAEs with and without CDI occurring in 2018. METHODS This retrospective cohort study assessed CDI incidence and associated mortality and costs for eligible MAEs ≥65 years of age using the de-identified Optum Clinformatics Data Mart database (Optum; Eden Prairie, Minnesota, USA). Outcomes included mortality, healthcare utilization, and costs, which were assessed via a propensity score-matched cohort using 2018 as the index year. Outcome analyses were stratified by infection acquisition and hospitalization status. RESULTS From 2012 to 2019, overall annual CDI incidence declined from 609 to 442 per 100 000 person-years. Although the incidence of healthcare-associated CDI declined overall (2012, 53.2%; 2019, 47.2%), community-associated CDI increased (2012, 46.8%; 2019, 52.8%). The 1-year attributable mortality was 7.9% (CDI cases, 26.3%; non-CDI controls, 18.4%). At the 2-month follow-up, CDI-associated excess mean total healthcare and out-of-pocket costs were $13 476 and $396, respectively. Total excess mean healthcare costs were greater among hospitalized (healthcare-associated, $28 762; community-associated, $28 330) than nonhospitalized CDI patients ($5704 and $2320, respectively), whereas total excess mean out-of-pocket cost was highest among community-associated hospitalized CDI patients ($970). CONCLUSIONS CDI represents an important public health burden in the MAE population. Preventive strategies and treatments are needed to improve outcomes and reduce costs for healthcare systems and this growing population of older US adults.
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Affiliation(s)
- Holly Yu
- Correspondence: H. Yu, Pfizer Inc, 500 Arcola Road, Collegeville, PA 19426 ()
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2
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Haran JP, Ward DV, Bhattarai SK, Loew E, Dutta P, Higgins A, McCormick BA, Bucci V. The high prevalence of Clostridioides difficile among nursing home elders associates with a dysbiotic microbiome. Gut Microbes 2022; 13:1-15. [PMID: 33764826 PMCID: PMC8007149 DOI: 10.1080/19490976.2021.1897209] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile disproportionally affects the elderly living in nursing homes (NHs). Our objective was to explore the prevalence of C. difficile in NH elders, over time and to determine whether the microbiome or other clinical factors are associated with C. difficile colonization.We collected serial stool samples from NH residents. C. difficile prevalence was determined by quantitative polymerase-chain reaction detection of Toxin genes tcdA and tcdB; microbiome composition was determined by shotgun metagenomic sequencing. We used mixed-effect random forest modeling machine to determine bacterial taxa whose abundance is associated with C. difficile prevalence while controlling for clinical covariates including demographics, medications, and past medical history.We enrolled 167 NH elders who contributed 506 stool samples. Of the 123 elders providing multiple samples, 30 (24.4%) elders yielded multiple samples in which C. difficile was detected and 78 (46.7%) had at least one C. difficile positive sample. Elders with C. difficile positive samples were characterized by increased abundances of pathogenic or inflammatory-associated bacterial taxa and by lower abundances of taxa with anti-inflammatory or symbiotic properties. Proton pump inhibitor (PPI) use is associated with lower prevalence of C. difficile (Odds Ratio 0.46; 95%CI, 0.22-0.99) and the abundance of bacterial species with known beneficial effects was higher in PPI users and markedly lower in elders with high C. difficile prevalence.C. difficile is prevalent among NH elders and a dysbiotic gut microbiome associates with C. difficile colonization status. Manipulating the gut microbiome may prove to be a key strategy in the reduction of C. difficile in the NH.
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Affiliation(s)
- John P. Haran
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA,Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA,CONTACT John P. Haran Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA01655
| | - Doyle V. Ward
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Shakti K. Bhattarai
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ethan Loew
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Protiva Dutta
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Amanda Higgins
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Beth A. McCormick
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Vanni Bucci
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA,Program in Microbiome Dynamics, University of Massachusetts Medical School, Worcester, MA, USA
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Sommermeyer H, Pituch HM, Wultanska D, Wojtyla-Buciora P, Piatek J, Bernatek M. Inhibition of Quinolone- and Multi-Drug-Resistant Clostridioides Difficile Strains by Multi Strain Synbiotics-An Option for Diarrhea Management in Nursing Facilities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:5871. [PMID: 34070727 PMCID: PMC8198539 DOI: 10.3390/ijerph18115871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/18/2021] [Accepted: 05/28/2021] [Indexed: 12/17/2022]
Abstract
Diarrhea is a common problem in nursing homes. A survey among nursing facilities in Poland was used to characterize diarrhea outbreaks, the burden caused for residents and caregivers and the employed measures. Survey results confirmed that diarrhea is a common problem in nursing homes and in most cases affects groups of residents. The related burden is high or very high for 27% of residents and 40% of caregivers. In 80% of nursing facilities pro or synbiotics are part of the measures used to manage diarrhea. Administration of these kinds of products has been suggested for the management of diarrhea, especially in cases caused by Clostridioides (C.) difficile. C. difficile is one of many potential causes for diarrhea, but is of particular concern for nursing homes because it is responsible for a large proportion of diarrhea outbreaks and is often caused by multi-drug resistant strains. In vitro inhibition of a quinolone-resistant and a multi-drug resistant C. difficile strain was used to evaluate the growth inhibitory effects of commonly used products containing probiotic microorganisms. Growth of both strains was best inhibited by multi-strain synbiotic preparations. These findings suggest that multi-strain synbiotics can be considered as an interventional option for diarrhea caused by C. difficile.
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Affiliation(s)
- Henning Sommermeyer
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
| | - Hanna M. Pituch
- Department of Medical Microbiology, Medical University of Warsaw, ul. Żwirki i Wigury 61, 02-091 Warsaw, Poland; (H.M.P.); (D.W.)
| | - Dorota Wultanska
- Department of Medical Microbiology, Medical University of Warsaw, ul. Żwirki i Wigury 61, 02-091 Warsaw, Poland; (H.M.P.); (D.W.)
| | - Paulina Wojtyla-Buciora
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
| | - Jacek Piatek
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
| | - Malgorzata Bernatek
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
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4
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The use of laboratory-identified event surveillance to classify adverse outcomes due to Clostridioides difficile infection in Canadian long-term care facilities. Infect Control Hosp Epidemiol 2020; 42:557-564. [PMID: 33222722 DOI: 10.1017/ice.2020.1269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adverse outcomes following Clostridioides difficile infection (CDI) are not often reported for long-term care facility (LTCF) residents. We focused on the adverse outcomes due to CDI identified in Alberta LTCFs. METHODS All positive Clostridioides difficile stool specimens identified by laboratory-identified (LabID) event surveillance in Alberta from 2011 to 2018, along with Alberta Continuing Care Information System, were used to define CDI in Alberta LTCFs. CDI cases were classified as long-term care onset, hospital onset, and community onset. Laboratory records were linked to provincial databases to analyze acute-care admissions and mortality within 30-day post CDI. Age, sex, case classification, episode, and operator type, were investigated using logistic regression. RESULTS Overall, 902 CDI cases were identified in 762 LTCF residents. Of all CDI events, 860 (95.3%) were long-term care onset, 38 (4.2%) were hospital onset, and 4 (0.4%) were community onset. The CDI rate was 2.0 of 100,000 resident days. In total, 157 residents (20.6%) had 30-day all-cause mortality, 126 CDI cases (14.0%) had 30-day all-cause acute-care admissions. The 30-day all-cause mortality rate was significantly higher in residents aged >80 versus ≤80 years (24.9 vs 12.3 per 100 residents; P < .05). Residents aged >80 years, with hospital-onset CDI, and those staying in private or voluntary LTCFs were more likely to have 30-day all-cause acute-care admissions. CONCLUSIONS The prevalence of CDI adverse outcomes is in LTCFs was found to be high using LabID event surveillance. Annual review of CDI adverse outcomes using LabID event can minimize the burden of surveillance and standardize the process across all Alberta LTCFs.
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McConeghy KW, Zullo AR, Lary CW, Zhang T, Lee Y, Daiello L, Kiel DP, Berry S. Association Between Bisphosphonates and Hospitalized Clostridioides difficile Infection Among Frail Older Adults. J Am Med Dir Assoc 2020; 21:688-691. [PMID: 31932139 DOI: 10.1016/j.jamda.2019.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Clostridioides difficile infection is a major source of morbidity and mortality among frail older adults, especially those in nursing homes (NHs). Safety reports have signaled that bisphosphonate use may be a contributing cause. We therefore evaluated the risk of C difficile hospitalization associated with oral bisphosphonate use in the NH. DESIGN Observational, retrospective new-user cohort study. SETTING The cohort included US NH residents aged ≥65 years who became a long-stay resident (>100 days in the NH) between January 1, 2008 and December 31, 2009. METHODS We conducted a study of NH residents using linked Medicare claims and Minimum Data Set records. Residents were new users of an oral bisphosphonate 1:1 matched to new calcitonin users ("active" comparator) on propensity scores controlling for more than 100 covariates. The outcome was risk of hospitalization for C difficile infection in a Cox proportional hazards model adjusted for previous antibiotic and proton pump inhibitor use. RESULTS Our final analytical cohort included 17,753 bisphosphonate and 5348 calcitonin users. In the matched cohort, 84/5209 (1.6%) vs 71/5209 (1.4%) C difficile-related hospitalizations occurred in bisphosphonate and calcitonin users, respectively. We observed no significant difference in the risk of hospitalization among bisphosphonate users (hazard ratio: 1.11, 95% confidence interval: 0.80-1.51). Antibiotic and proton pump inhibitor exposure before and after osteoporosis treatment was also similar between bisphosphonate and calcitonin users. CONCLUSIONS AND IMPLICATIONS C difficile infection should not be a consideration when prescribing bisphosphonates to frail older adults given the lack of a significant association.
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Affiliation(s)
- Kevin W McConeghy
- Center of Innovation Long-term Services and Support, Providence Veterans Affairs Medical Center, Providence, RI; School of Public Health Brown University, Providence, RI; University of Rhode Island, College of Pharmacy, Kingston, RI.
| | - Andrew R Zullo
- Center of Innovation Long-term Services and Support, Providence Veterans Affairs Medical Center, Providence, RI; School of Public Health Brown University, Providence, RI
| | - Christine W Lary
- Maine Medical Center for Outcomes Research & Evaluation, Portland, ME
| | - Tingting Zhang
- Center of Innovation Long-term Services and Support, Providence Veterans Affairs Medical Center, Providence, RI; School of Public Health Brown University, Providence, RI
| | - Yoojin Lee
- Center of Innovation Long-term Services and Support, Providence Veterans Affairs Medical Center, Providence, RI; School of Public Health Brown University, Providence, RI
| | - Lori Daiello
- School of Public Health Brown University, Providence, RI
| | - Douglas P Kiel
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA
| | - Sarah Berry
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA
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6
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Decreased Fecal Bacterial Diversity and Altered Microbiome in Children Colonized With Clostridium difficile. J Pediatr Gastroenterol Nutr 2019; 68:502-508. [PMID: 30540709 DOI: 10.1097/mpg.0000000000002210] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The gut microbiome is believed to play a role in the susceptibility to and treatment of Clostridium difficile infections (CDIs). It is, however, unknown whether the gut microbiome is also affected by asymptomatic C difficile colonization. Our study aimed to evaluate the fecal microbiome of children based on C difficile colonization, and CDI risk factors, including antibiotic use and comorbid inflammatory bowel disease (IBD). METHODS Subjects with IBD and non-IBD controls were prospectively enrolled from pediatric clinics for a biobanking project (n = 113). A fecal sample was collected from each subject for research purposes only and was evaluated for asymptomatic toxigenic C difficile colonization. Fecal microbiome composition was determined by 16S rRNA sequencing. RESULTS We found reduced bacterial diversity and altered microbiome composition in subjects with C difficile colonization, concurrent antibiotic use, and/or concomitant IBD (all P < 0.05). Accounting for antibiotic use and IBD status, children colonized with C difficile had significant enrichment in taxa from the genera Ruminococcus, Eggerthella, and Clostridium. Children without C difficile had increased relative abundances of Faecalibacterium and Rikenellaceae. Imputed metagenomic functions of those colonized were enriched for genes in oxidative phosphorylation and beta-lactam resistance, whereas in the subjects without C difficile, several functions in translation and metabolism were over-represented. CONCLUSIONS In children, C difficile colonization, or factors that predispose to colonization such as antibiotic use and IBD status were associated with decreased gut bacterial diversity and altered microbiome composition. Averting such microbiome alterations may be a method to prevent or treat CDI.
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7
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Balsells E, Shi T, Leese C, Lyell I, Burrows J, Wiuff C, Campbell H, Kyaw MH, Nair H. Global burden of Clostridium difficile infections: a systematic review and meta-analysis. J Glob Health 2019; 9:010407. [PMID: 30603078 PMCID: PMC6304170 DOI: 10.7189/jogh.09.010407] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Clostridium difficile is a leading cause of morbidity and mortality in several countries. However, there are limited evidence characterizing its role as a global public health problem. We conducted a systematic review to provide a comprehensive overview of C. difficile infections (CDI) rates. Methods Seven databases were searched (January 2016) to identify studies and surveillance reports published between 2005 and 2015 reporting CDI incidence rates. CDI incidence rates for health care facility-associated (HCF), hospital onset-health care facility-associated, medical or general intensive care unit (ICU), internal medicine (IM), long-term care facility (LTCF), and community-associated (CA) were extracted and standardized. Meta-analysis was conducted using a random effects model. Results 229 publications, with data from 41 countries, were included. The overall rate of HCF-CDI was 2.24 (95% confidence interval CI = 1.66-3.03) per 1000 admissions/y and 3.54 (95%CI = 3.19-3.92) per 10 000 patient-days/y. Estimated rates for CDI with onset in ICU or IM wards were 11.08 (95%CI = 7.19-17.08) and 10.80 (95%CI = 3.15-37.06) per 1000 admission/y, respectively. Rates for CA-CDI were lower: 0.55 (95%CI = 0.13-2.37) per 1000 admissions/y. CDI rates were generally higher in North America and among the elderly but similar rates were identified in other regions and age groups. Conclusions Our review highlights the widespread burden of disease of C. difficile, evidence gaps, and the need for sustainable surveillance of CDI in the health care setting and the community.
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Affiliation(s)
- Evelyn Balsells
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint first authorship
| | - Ting Shi
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint first authorship
| | - Callum Leese
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Iona Lyell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - John Burrows
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Moe H Kyaw
- Sanofi Pasteur, Swiftwater, Pennsylvania, USA.,Joint last authorship
| | - Harish Nair
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Joint last authorship
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8
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Fukuda H, Yano T, Shimono N. Inpatient Expenditures Attributable to Hospital-Onset Clostridium difficile Infection: A Nationwide Case-Control Study in Japan. PHARMACOECONOMICS 2018; 36:1367-1376. [PMID: 30022364 DOI: 10.1007/s40273-018-0692-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Hospital-onset Clostridium difficile infections (CDIs) have a considerable clinical and economic impact on patients and payers. Quantifying the economic impact of CDIs can guide treatment strategies. However, previous studies have generally focused on acute care hospitals, and few have included cost estimates from non-acute care hospitals such as long-term care facilities. AIM This study aimed to quantify the hospital-onset CDI-attributable inpatient expenditures and length-of-stay durations in all healthcare institutions that provide inpatient care (including acute and non-acute care) in Japan. METHODS Using national-level insurance claims data, we analyzed patients who had been hospitalized between April 2010 and December 2016. CDI cases were identified and matched with non-CDI controls using hospitalization year, treating hospital, age, sex, surgical procedure, comorbidities, and main diagnoses. Through multivariable regression analyses, we estimated the CDI-attributable inpatient expenditures (2016 US dollars) and length-of-stay durations (days) while adjusting for variations in factors such as patient characteristics, comorbidities, surgery, prescribed antibiotic, geographic region, and hospitalization year. We also analyzed the CDI-attributable inpatient expenditures and length-of-stay durations according to hospital type (acute care and rehabilitation/long-term care). RESULTS The analysis was conducted using 3768 matched pairs. Overall, CDI-attributable inpatient expenditures and length-of-stay durations were US$3213 and 11.96 days, respectively. Rehabilitation/long-term care hospitals had substantially higher inpatient expenditures and longer hospitalizations than acute care hospitals. CONCLUSION This study quantified the hospital-onset CDI-attributable inpatient expenditures and hospitalizations in both acute and non-acute care hospitals. The inclusion of non-acute care hospitals provides a more accurate representation of the economic burden of CDIs.
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Affiliation(s)
- Haruhisa Fukuda
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan.
| | - Takahisa Yano
- Center for the Study of Global Infection, Kyushu University Hospital, Fukuoka, Japan
| | - Nobuyuki Shimono
- Center for the Study of Global Infection, Kyushu University Hospital, Fukuoka, Japan
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9
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Mallia G, Van Toen J, Rousseau J, Jacob L, Boerlin P, Greer A, Metcalf D, Weese J. Examining the epidemiology and microbiology of Clostridium difficile carriage in elderly patients and residents of a healthcare facility in southern Ontario, Canada. J Hosp Infect 2018; 99:461-468. [DOI: 10.1016/j.jhin.2018.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/27/2018] [Indexed: 11/28/2022]
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Transmission of Clostridium difficile from asymptomatically colonized or infected long-term care facility residents. Infect Control Hosp Epidemiol 2018; 39:909-916. [PMID: 29848392 DOI: 10.1017/ice.2018.106] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions. DESIGN A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS). SETTING Veterans Affairs hospital and affiliated LTCF.ParticipantsThe study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases. RESULTS Of the 37 CDI cases, 7 (18·9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11·5%) and 4 of 11 LTCF-associated cases (36·4%). Of the 7 transmissions linked to LTCF residents, 5 (71·4%) were linked to asymptomatic carriers versus 2 (28·6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases. CONCLUSIONS Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.
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Abstract
Recent increases in the incidence of Clostridium difficile infection (CDI) have been observed in all age groups, but the elderly have been disproportionately affected and long-term care facilities (LTCFs) have borne a significant proportion of the increasing burden. Recurrences are common in older adults and may have significant adverse effects on quality of life. Ensuring appropriate diagnostic testing and management is challenging for older adults in the community and in LTCFs. This review focuses on current concepts related to the epidemiology, diagnosis, and management of CDI in older adults.
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Affiliation(s)
- Curtis J Donskey
- Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106, USA; Case Western Reserve University School of Medicine, 10,000 Euclid Avenue, Cleveland, OH 44106, USA.
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12
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High Prevalence and Frequent Acquisition of Clostridium difficile Ribotype 002 Among Nursing Home Residents in Hong Kong. Infect Control Hosp Epidemiol 2018; 39:782-787. [PMID: 29733004 DOI: 10.1017/ice.2018.92] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVETo determine the incidence and risk factors associated with Clostridium difficile colonization among residents of nursing homes and to identify the ribotypes of circulating C. difficile strains.DESIGNA prospective cohort study with a follow-up duration of 22 months.SETTINGNursing homes.PARTICIPANTSOf the 375 residents in 8 nursing homes, 300 residents (80.0%) participated in the study. A further prospective study of 4 nursing homes involving 141 residents with a minimum of 90 days of follow-up was also performed.METHODSBaseline and 90-day stool cultures were obtained; additional stool cultures were obtained for residents who had been discharged from hospitals. Polymerase chain reaction (PCR) ribotyping and slpA typing were performed for all C. difficile strains isolated.RESULTSToxigenic C. difficile was isolated in 30 residents (10%) at baseline, and 9 residents (7.3%) had acquired toxigenic C. difficile in the nursing homes. The presence of nasogastric tube was an independent risk factor (adjusted odds ratio, 8.59; 95% confidence interval, 1.18-62.53; P=.034) for C. difficile colonization. The Kaplan-Meier estimate of median carriage duration was 13 weeks. The C. difficile ribotypes most commonly identified were 002 (40.8%), 014 (16.9%), 029 (9.9%), and 053 (8.5%).CONCLUSIONSThe high incidence of C. difficile colonization and the overrepresentation of C. difficile ribotype 002 confirmed the contribution of nursing home residents to C. difficile transmission across the continuum of care. An infection control program is needed in long-term care.Infect Control Hosp Epidemiol 2018;782-787.
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Schäffler H, Breitrück A. Clostridium difficile - From Colonization to Infection. Front Microbiol 2018; 9:646. [PMID: 29692762 PMCID: PMC5902504 DOI: 10.3389/fmicb.2018.00646] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/19/2018] [Indexed: 12/19/2022] Open
Abstract
Clostridium difficile is the most frequent cause of nosocomial antibiotic-associated diarrhea. The incidence of C. difficile infection (CDI) has been rising worldwide with subsequent increases in morbidity, mortality, and health care costs. Asymptomatic colonization with C. difficile is common and a high prevalence has been found in specific cohorts, e.g., hospitalized patients, adults in nursing homes and in infants. However, the risk of infection with C. difficile differs significantly between these cohorts. While CDI is a clear indication for therapy, colonization with C. difficile is not believed to be a direct precursor for CDI and therefore does not require treatment. Antibiotic therapy causes alterations of the intestinal microbial composition, enabling C. difficile colonization and consecutive toxin production leading to disruption of the colonic epithelial cells. Clinical symptoms of CDI range from mild diarrhea to potentially life-threatening conditions like pseudomembranous colitis or toxic megacolon. While antibiotics are still the treatment of choice for CDI, new therapies have emerged in recent years such as antibodies against C. difficile toxin B and fecal microbial transfer (FMT). This specific therapy for CDI underscores the role of the indigenous bacterial composition in the prevention of the disease in healthy individuals and its role in the pathogenesis after alteration by antibiotic treatment. In addition to the pathogenesis of CDI, this review focuses on the colonization of C. difficile in the human gut and factors promoting CDI.
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Affiliation(s)
- Holger Schäffler
- Division of Gastroenterology, Department of Medicine II, University of Rostock, Rostock, Germany
| | - Anne Breitrück
- Extracorporeal Immunomodulation Unit, Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany.,Institute of Medical Microbiology, Virology and Hygiene, University of Rostock, Rostock, Germany
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Durovic A, Widmer AF, Tschudin-Sutter S. New insights into transmission of Clostridium difficile infection-narrative review. Clin Microbiol Infect 2018; 24:483-492. [PMID: 29427800 DOI: 10.1016/j.cmi.2018.01.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 01/22/2018] [Accepted: 01/27/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Traditionally, Clostridium difficile has been considered a typical healthcare-associated pathogen-that is, one transmitted within healthcare facilities and thus prevented by implementation of standard infection control measures. Recently this concept has been challenged by studies suggesting a relevant role for community acquisition of C. difficile. AIMS To discusses the current literature, compiled during the last decade, reporting on sources of acquisition of C. difficile and subsequent transmission. SOURCES The databases PubMed, Medline, Embase and the Cochrane Database were searched for articles published from 1 January 2007 to 30 June 2017 reporting on possible transmission pathways of C. difficile and/or suggesting a source of acquisition of C. difficile. All study types reporting on adult populations were considered; case reports and series were excluded. The PRISMA guidelines for the reporting of systematic reviews were followed. CONTENT Among 24 original articles included, 63% report on transmission of C. difficile in healthcare settings and 37% investigate sources and transmission of C. difficile in the community. Contact with symptomatic carriers (53.3%), the hospital environment (40.0%) and asymptomatic carriers (20%) were the most commonly reported transmission pathways within healthcare settings. The leading sources for acquisition of C. difficile in the community include direct contact with symptomatic and asymptomatic carriers in the community, including infants (30%) and residents of long-term non-acute care facilities (30%), followed by contact with contaminated environments in outpatient care settings (20%) and exposure to livestock or livestock farms (20%). IMPLICATIONS In healthcare settings, future control efforts may need to focus on extending cleaning and disinfection procedures beyond the immediate surroundings of symptomatic carriers. Potential targets to prevent acquisition of C. difficile in the community include household settings, long-term care facilities and outpatient settings, while the role of livestock in entertaining transmission requires further investigation.
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Affiliation(s)
- A Durovic
- Medical University Department, Division of Oncology and Hematology, Kantonsspital Aarau, Aarau, Switzerland
| | - A F Widmer
- Department of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - S Tschudin-Sutter
- Department of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland.
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Abstract
Clostridium difficile is the most frequent cause of nosocomial antibiotic-associated diarrhea. The incidence of C. difficile infection (CDI) has been rising worldwide with subsequent increases in morbidity, mortality, and health care costs. Asymptomatic colonization with C. difficile is common and a high prevalence has been found in specific cohorts, e.g., hospitalized patients, adults in nursing homes and in infants. However, the risk of infection with C. difficile differs significantly between these cohorts. While CDI is a clear indication for therapy, colonization with C. difficile is not believed to be a direct precursor for CDI and therefore does not require treatment. Antibiotic therapy causes alterations of the intestinal microbial composition, enabling C. difficile colonization and consecutive toxin production leading to disruption of the colonic epithelial cells. Clinical symptoms of CDI range from mild diarrhea to potentially life-threatening conditions like pseudomembranous colitis or toxic megacolon. While antibiotics are still the treatment of choice for CDI, new therapies have emerged in recent years such as antibodies against C. difficile toxin B and fecal microbial transfer (FMT). This specific therapy for CDI underscores the role of the indigenous bacterial composition in the prevention of the disease in healthy individuals and its role in the pathogenesis after alteration by antibiotic treatment. In addition to the pathogenesis of CDI, this review focuses on the colonization of C. difficile in the human gut and factors promoting CDI.
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Affiliation(s)
- Holger Schäffler
- Division of Gastroenterology, Department of Medicine II, University of Rostock, Rostock, Germany
| | - Anne Breitrück
- Extracorporeal Immunomodulation Unit, Fraunhofer Institute for Cell Therapy and Immunology, Rostock, Germany
- Institute of Medical Microbiology, Virology and Hygiene, University of Rostock, Rostock, Germany
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16
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Zheng S, Shao S, Qiao Z, Chen X, Piao C, Yu Y, Gao F, Zhang J, Du J. Clinical Parameters and Gut Microbiome Changes Before and After Surgery in Thoracic Aortic Dissection in Patients with Gastrointestinal Complications. Sci Rep 2017; 7:15228. [PMID: 29123168 PMCID: PMC5680333 DOI: 10.1038/s41598-017-15079-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 10/20/2017] [Indexed: 01/07/2023] Open
Abstract
Thoracic aortic dissection (TAAD) is one of the most common types of aortic diseases. Although surgery remains the main method of treatment, the high rate of postoperative gastrointestinal complications significantly influences the effects of surgery and the recovery process. Moreover, the mechanisms underlying this disease remain unclear. To address these problems, we examined changes in the gut microbiota in 40 thoracic aortic dissection patients with abdominal complications after surgery. Levels of white blood cells (WBC), neutrophile granulocytes (NE), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were higher in all patients after surgery. Levels of inflammatory cytokines, including interleukin (IL)-2, IL-6, IL-8, and IL-10, were also higher after surgery. A metagenome analysis revealed that levels of Oscillibacter, Anaerotruncus, Alistipes, and Clostridium difficile were higher after the operation. The abundance of functional genes, such as the spermidine/putrescine transport system permease protein, the flagellar motor switch protein, and branched-chain amino acid transport system proteins, was also higher post-surgery. These changes likely contribute to diarrhea, bloating, gastrointestinal bleeding, and other abdominal complications after surgery, and our research opens up new treatment possibilities for patients suffering from abdominal complications after surgical treatment.
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Affiliation(s)
- Shuai Zheng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.,Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, 100029, China.,The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, 100029, China
| | - Shulin Shao
- Department of Gastroenterology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Zhiyu Qiao
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing, 100029, China
| | - Xue Chen
- Department of Gastroenterology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Chunmei Piao
- Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.,Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, 100029, China.,The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, 100029, China
| | - Ying Yu
- Department of Gastroenterology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Feng Gao
- Department of Gastroenterology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Jie Zhang
- Department of Gastroenterology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
| | - Jie Du
- Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China. .,Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, 100029, China. .,The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, 100029, China.
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Acquisition of Clostridium difficile Colonization and Infection After Transfer From a Veterans Affairs Hospital to an Affiliated Long-Term Care Facility. Infect Control Hosp Epidemiol 2017; 38:1070-1076. [DOI: 10.1017/ice.2017.140] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUNDClostridium difficile infection (CDI) and asymptomatic carriage of toxigenic C. difficile are common in long-term care facilities (LTCFs). However, whether C. difficile is frequently acquired in the LTCF versus during acute-care admissions remains unknown.OBJECTIVETo test the hypothesis that LTCF residents often acquire C. difficile colonization and infection in the LTCFDESIGNThis 5-month cohort study was conducted to determine the incidence of acquisition of C. difficile colonization and infection in asymptomatic patients transferred from a Veterans Affairs hospital to an affiliated LTCF.METHODSRectal swabs were cultured for toxigenic C. difficile at the time of transfer to the LTCF and weekly for up to 6 weeks. We calculated the proportion of LTCF-onset CDI cases within 1 month of transfer that occurred in residents colonized on admission versus those with new acquisition in the LTCF.RESULTSOf 110 patients transferred to the LTCF, 12 (11%) were asymptomatically colonized with toxigenic C. difficile upon admission, and 4 of these 12 patients (33%) developed CDI within 1 month, including 3 recurrent and 1 initial CDI episode. Of 82 patients with negative cultures on transfer and at least 1 follow-up culture, 22 (27%) acquired toxigenic C. difficile colonization, and 4 developed CDI within 1 month, including 1 recurrent and 3 initial CDI episodes.CONCLUSIONLTCF residents frequently acquired colonization with toxigenic C. difficile after transfer from the hospital, and 3 of 4 initial CDI cases with onset within 1 month of transfer occurred in residents who acquired colonization in the LTCF.Infect Control Hosp Epidemiol 2017;38:1070–1076
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18
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Joyce NR, Mylonakis E, Mor V. Effect of Clostridium difficile Prevalence in Hospitals and Nursing Homes on Risk of Infection. J Am Geriatr Soc 2017; 65:1527-1534. [PMID: 28394408 DOI: 10.1111/jgs.14838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To assess the effect of facility Clostridium difficile infection (CDI) prevalence on risk of healthcare facility (HFC) acquired CDI. DESIGN Retrospective cohort study. SETTING Medicare fee-for-service (FFS) claims and skilled nursing facility (SNF) Minimum Data Set 3.0 assessments. PARTICIPANTS Medicare beneficiaries with 90 days or more of no contact with a HCF before a hospital admission without a CDI diagnosis. Participants were separated into two cohorts: discharged to the community and discharged to a SNF. MEASUREMENTS Risk of HCF-acquired CDI associated with CDI prevalence at the index facility measured according to 30-day rehospitalization with a discharge diagnosis of CDI or diagnosis in the SNF after admission. Hospital and SNF CDI prevalence were categorized into three groups: 0% and above and below the median value for facilities with greater than 0% prevalence. RESULTS Of 817,900 eligible individuals, there were 553,423 admissions in the first cohort (discharged to the community) and 315,109 in the second (discharged to a SNF). In the first cohort, the risk of HCF-acquired CDI was higher for individuals admitted to hospitals with CDI prevalence less than the median (relative risk (RR) = 1.58, 95% confidence interval (CI) = 1.18-2.12) and greater than the median (RR = 2.56, 95% CI = 1.91-3.45) than for those with no CDI. In the second cohort, the risk of HCF-acquired CDI was greater for individuals admitted to a hospital (RR = 1.89, 95% CI = 1.49-2.39) and a SNF (RR = 1.48, 95% CI = 1.31-1.67) with CDI prevalence greater than the median. CONCLUSION The risk of HCF-acquired CDI is greater for noninfected individuals admitted to hospitals and SNFs with a high prevalence of CDI.
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Affiliation(s)
- Nina R Joyce
- Department of Health Care Policy, School of Medicine, Harvard University, Boston, Massachusetts
| | | | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island.,Providence Veterans Administration Medical Center, Providence, Rhode Island
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Yu H, Baser O, Wang L. Burden of Clostridium difficile-associated disease among patients residing in nursing homes: a population-based cohort study. BMC Geriatr 2016; 16:193. [PMID: 27884118 PMCID: PMC5123396 DOI: 10.1186/s12877-016-0367-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/16/2016] [Indexed: 01/11/2023] Open
Abstract
Background Clostridium difficile (C. difficile) infection (CDI) is the leading cause of nosocomial diarrhea in the United States. This study aimed to examine the incidence of CDI and evaluate mortality and economic burden of CDI in an elderly population who reside in nursing homes (NHs). Methods This was a population-based retrospective cohort study focusing on US NHs by linking Medicare 5% sample, Medicaid, Minimum Data Set (MDS) (2008–10). NH residents aged ≥65 years with continuous enrollment in Medicare and/or Medicaid Fee-for-Service plan for ≥12 months and ≥2 quarterly MDS assessments were eligible for the study. The incidence rate was calculated as the number of CDI episodes by 100,000 person-years. A 1:4 propensity score matched sample of cohorts with and without CDI was generated to assess mortality and health care costs following the first CDI. Results Among 32,807 NH residents, 941 residents had ≥1 episode of CDI in 2009, with an incidence of 3359.9 per 100,000 person-years. About 30% CDI episodes occurred in the hospital setting. NH residents with CDI (vs without CDI) were more likely to have congestive heart failure, renal disease, cerebrovascular disease, hospitalizations, and outpatient antibiotic use. During the follow-up period, the 30-day (14.7% vs 4.3%, P < 0.001), 60-day (22.7% vs 7.5%, P < 0.001), 6-month (36.3% vs 18.3%, P < 0.001), and 1-year mortality rates (48.2% vs 31.1%, P < 0.001) were significantly higher among the CDI residents vs non-CDI residents. Total health care costs within 2 months following the first CDI episode were also significantly higher for CDI residents ($28,621 vs $13,644, P < 0.001). Conclusions CDI presents a serious public health issue in NHs. Mortality, health care utilization, and associated costs were significant following incident CDI episodes. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0367-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Holly Yu
- Pfizer Inc, Arcola Road, Collegeville, PA, 19426, USA.
| | - Onur Baser
- Center for Innovation & Outcomes Research, Department of Surgery, Columbia University, New York, NY, USA.,STATinMED Research, New York, NY, USA
| | - Li Wang
- STATinMED Research, Plano, TX, USA
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20
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Chopra T, Awali RA, Biedron C, Vallin E, Bheemreddy S, Saddler CM, Mullins K, Echaiz JF, Bernabela L, Severson R, Marchaim D, Lephart P, Johnson L, Thyagarajan R, Kaye KS, Alangaden G. Predictors of Clostridium difficile infection-related mortality among older adults. Am J Infect Control 2016; 44:1219-1223. [PMID: 27424303 DOI: 10.1016/j.ajic.2016.04.231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/01/2016] [Accepted: 04/01/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over 90% of annual deaths caused by Clostridium difficile infection (CDI) occur in persons aged ≥65 years. However, no large-scale studies have been conducted to investigate predictors of CDI-related mortality among older adults. METHODS This case-control study included 540 CDI patients aged ≥60 years admitted to a tertiary care hospital in Detroit, Michigan, between January 2005 and December 2012. Cases were CDI patients who died within 30 days of CDI date. Controls were CDI patients who survived >30 days after CDI date. Cases were matched to controls on a 1:3 ratio based on age and hospital acquisition of CDI. RESULTS One-hundred and thirty cases (25%) were compared with 405 controls (75%). Independent predictors of CDI-related mortality included admission from another acute hospital (odds ratio [OR], 8.25; P = .001) or a long-term care facility (OR, 13.12; P = .012), McCabe score ≥2 (OR, 12.19; P < .001), and high serum creatinine (≥1.7 mg/dL) (OR, 3.43; P = .021). The regression model was adjusted for the confounding effect of limited activity of daily living score, total number of antibiotic days prior to CDI, ileus on abdominal radiograph, low albumin (≤2.5 g/dL), elevated white blood cell count (>15 × 1,000/mm3), and admission to intensive care unit because of CDI. CONCLUSIONS Predictors of CDI-related mortality reported in this study could be applied to the development of a bedside scoring system for older adults with CDI.
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21
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Awali RA, Kandipalli D, Pervaiz A, Narukonda S, Qazi U, Trehan N, Chopra T. Risk factors associated with interfacility transfers among patients with Clostridium difficile infection. Am J Infect Control 2016; 44:1027-31. [PMID: 27207161 DOI: 10.1016/j.ajic.2016.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/23/2016] [Accepted: 03/02/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Preventing the transmission of Clostridium difficile infection (CDI) over the continuum of care presents an important challenge for infection control. METHODS A prospective case-control study was conducted on patients admitted with CDI to a tertiary care hospital in Detroit between August 2012 and September 2013. Patients were then followed for 1 year by telephone interviews and the hospital administrative database. Cases, patients with interfacility transfers (IFTs), were patients admitted to our facility from another health care facility and discharged to long-term care (LTC) facilities. Controls were patients admitted from and discharged to home. RESULTS There were 143 patients included in the study. Thirty-six (30%) cases were compared with 84 (70%) controls. Independent risk factors of CDI patients with IFTs (compared with CDI patients without IFTs) included Charlson Comorbidity Index score ≥6 (odds ratio [OR], 5.30; P = .016) and hospital-acquired CDI (OR, 4.92; P = .023). Patients with IFTs were more likely to be readmitted within 90 days of discharge than patients without IFTs (OR, 2.24; P = .046). One-year mortality rate was significantly higher among patients with IFTs than among patients without IFTs (OR, 4.33; P = .01). CONCLUSIONS With the growing number of alternate health care centers, it is highly critical to establish better collaboration between acute care and LTC facilities to tackle the increasing burden of CDI across the health care system.
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Affiliation(s)
- Reda A Awali
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI.
| | - Deepthi Kandipalli
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Amina Pervaiz
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Sandhya Narukonda
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Urooj Qazi
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Naveen Trehan
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
| | - Teena Chopra
- Division of Infectious Diseases, Detroit Medical Center & Wayne State University, Detroit, MI
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22
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Clostridium difficile infection: epidemiology, diagnosis and understanding transmission. Nat Rev Gastroenterol Hepatol 2016; 13:206-16. [PMID: 26956066 DOI: 10.1038/nrgastro.2016.25] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Clostridium difficile infection (CDI) continues to affect patients in hospitals and communities worldwide. The spectrum of clinical disease ranges from mild diarrhoea to toxic megacolon, colonic perforation and death. However, this bacterium might also be carried asymptomatically in the gut, potentially leading to 'silent' onward transmission. Modern technologies, such as whole-genome sequencing and multi-locus variable-number tandem-repeat analysis, are helping to track C. difficile transmission across health-care facilities, countries and continents, offering the potential to illuminate previously under-recognized sources of infection. These typing strategies have also demonstrated heterogeneity in terms of CDI incidence and strain types reflecting different stages of epidemic spread. However, comparison of CDI epidemiology, particularly between countries, is challenging due to wide-ranging approaches to sampling and testing. Diagnostic strategies for C. difficile are complicated both by the wide range of bacterial targets and tests available and the need to differentiate between toxin-producing and non-toxigenic strains. Multistep diagnostic algorithms have been recommended to improve sensitivity and specificity. In this Review, we describe the latest advances in the understanding of C. difficile epidemiology, transmission and diagnosis, and discuss the effect of these developments on the clinical management of CDI.
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Hunter JC, Mu Y, Dumyati GK, Farley MM, Winston LG, Johnston HL, Meek JI, Perlmutter R, Holzbauer SM, Beldavs ZG, Phipps EC, Dunn JR, Cohen JA, Avillan J, Stone ND, Gerding DN, McDonald LC, Lessa FC. Burden of Nursing Home-Onset Clostridium difficile Infection in the United States: Estimates of Incidence and Patient Outcomes. Open Forum Infect Dis 2016; 3:ofv196. [PMID: 26798767 PMCID: PMC4719744 DOI: 10.1093/ofid/ofv196] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/07/2015] [Indexed: 01/05/2023] Open
Abstract
Background. Approximately 4 million Americans receive nursing home (NH) care annually. Nursing home residents commonly have risk factors for Clostridium difficile infection (CDI), including advanced age and antibiotic exposures. We estimated national incidence of NH-onset (NHO) CDI and patient outcomes. Methods. We identified NHO-CDI cases from population-based surveillance of 10 geographic areas in the United States. Cases were defined by C difficile-positive stool collected in an NH (or from NH residents in outpatient settings or ≤3 days after hospital admission) without a positive stool in the prior 8 weeks. Medical records were reviewed on a sample of cases. Incidence was estimated using regression models accounting for age and laboratory testing method; sampling weights were applied to estimate hospitalizations, recurrences, and deaths. Results. A total of 3503 NHO-CDI cases were identified. Among 262 sampled cases, median age was 82 years, 76% received antibiotics in the 12 weeks prior to the C difficile-positive specimen, and 57% were discharged from a hospital in the month before specimen collection. After adjusting for age and testing method, the 2012 national estimate for NHO-CDI incidence was 112 800 cases (95% confidence interval [CI], 93 400-131 800); 31 400 (28%) were hospitalized within 7 days after a positive specimen (95% CI, 25 500-37 300), 20 900 (19%) recurred within 14-60 days (95% CI, 14 600-27 100), and 8700 (8%) died within 30 days (95% CI, 6600-10 700). Conclusions. Nursing home onset CDI is associated with substantial morbidity and mortality. Strategies focused on infection prevention in NHs and appropriate antibiotic use in both NHs and acute care settings may decrease the burden of NHO CDI.
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Affiliation(s)
- Jennifer C Hunter
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases; Division of Scientific Education and Professional Development, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yi Mu
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
| | | | - Monica M Farley
- Department of Medicine, Emory University School of Medicine; Atlanta Veterans Affairs Medical Center, Georgia
| | - Lisa G Winston
- Department of Medicine , University of California, San Francisco School of Medicine
| | | | - James I Meek
- Connecticut Emerging Infections Program , Yale School of Public Health , New Haven
| | | | - Stacy M Holzbauer
- Minnesota Department of Health, St. Paul; Division of State and Local Readiness, Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response, Atlanta, Georgia
| | | | - Erin C Phipps
- New Mexico Emerging Infections Program , University of New Mexico , Albuquerque
| | | | - Jessica A Cohen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases; Atlanta Research and Education Foundation, Georgia
| | - Johannetsy Avillan
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
| | - Nimalie D Stone
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
| | - Dale N Gerding
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
| | - Fernanda C Lessa
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
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Clostridium difficile Infections in Veterans Health Administration Long-Term Care Facilities. Infect Control Hosp Epidemiol 2015; 37:295-300. [PMID: 26686361 DOI: 10.1017/ice.2015.309] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE A nationwide initiative was implemented in February 2014 to decrease Clostridium difficile infections (CDI) in Veterans Affairs (VA) long-term care facilities. We report a baseline of national CDI data collected during the 2 years before the Initiative. METHODS Personnel at each of 122 reporting sites entered monthly retrospective CDI case data from February 2012 through January 2014 into a national database using case definitions similar to those used in the National Healthcare Safety Network Multidrug-Resistant Organism/CDI module. The data were evaluated using Poisson regression models to examine infection occurrences over time while accounting for admission prevalence and type of diagnostic test. RESULTS During the 24-month analysis period, there were 100,800 admissions, 6,976,121 resident days, and 1,558 CDI cases. The pooled CDI admission prevalence rate (including recurrent cases) was 0.38 per 100 admissions, and the pooled nonduplicate/nonrecurrent community-onset rate was 0.17 per 100 admissions. The pooled long-term care facility-onset rate and the clinically confirmed (ie, diarrhea or evidence of pseudomembranous colitis) long-term care facility-onset rate were 1.98 and 1.78 per 10,000 resident days, respectively. Accounting for diagnostic test type, the long-term care facility-onset rate declined significantly (P=.05), but the clinically confirmed long-term care facility-onset rate did not. CONCLUSIONS VA long-term care facility CDI rates were comparable to those in recent reports from other long-term care facilities. The significant decline in the long-term care facility-onset rate but not in the clinically confirmed long-term care facility-onset rate may have been due to less testing of asymptomatic patients. Efforts to decrease CDI rates in long-term care facilities are necessary as part of a coordinated approach to decrease healthcare-associated infections.
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Miller R, Simmons S, Dale C, Stachowiak J, Stibich M. Utilization and impact of a pulsed-xenon ultraviolet room disinfection system and multidisciplinary care team on Clostridium difficile in a long-term acute care facility. Am J Infect Control 2015; 43:1350-3. [PMID: 26362699 DOI: 10.1016/j.ajic.2015.07.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 11/17/2022]
Abstract
Health care-associated transmission of Clostridium difficile has been well documented in long-term acute care facilities. This article reports on 2 interventions aimed at reducing the transmission risk: multidisciplinary care teams and no-touch pulsed-xenon disinfection. C difficile transmission rates were tracked over a 39-month period while these 2 interventions were implemented. After a baseline period of 1 year, multidisciplinary teams were implemented for an additional 1-year period with a focus on reducing C difficile infection. During this time, transmission rates dropped 17% (P = .91). In the following 15-month period, the multidisciplinary teams continued, and pulsed-xenon disinfection was added as an adjunct to manual cleaning of patient rooms and common areas. During this time, transmission rates dropped 57% (P = .02). These results indicate that the combined use of multidisciplinary teams and pulsed-xenon disinfection can have a significant impact on C difficile transmission rates in long-term care facilities.
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Mizusawa M, Doron S, Gorbach S. Clostridium difficile Diarrhea in the Elderly: Current Issues and Management Options. Drugs Aging 2015; 32:639-47. [DOI: 10.1007/s40266-015-0289-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Yoon SY, Jung SA, Na SK, Ryu JI, Yun HW, Lee MJ, Song EM, Kim SE, Jung HK, Shim KN. What's the Clinical Features of Colitis in Elderly People in Long-Term Care Facilities? Intest Res 2015; 13:128-34. [PMID: 25931997 PMCID: PMC4414754 DOI: 10.5217/ir.2015.13.2.128] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 10/12/2014] [Accepted: 10/13/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND/AIMS As life expectancy has increased, the number of elderly patients who need long-term care has grown rapidly. Mortality in patients with colitis in long-term care facilities (LTCFs) is increasing. We intend to investigate the main causes of colitis in LTCFs compared to those of colitis in local communities, and to identify the clinical features and risk factors of patients with colitis in LTCFs. METHODS We retrospectively analyzed epidemiology, medical conditions, laboratory values, diagnoses, and clinical courses of elderly patients aged ≥65 who were admitted to the Ewha Womans University hospital with colitis between January 2007 and July 2012. RESULTS Patients with colitis in LTCFs (n=20) were compared with elderly patients with colitis in local communities (n=154). Fifty-five percent of colitis in LTCFs was caused by Clostridium difficile infection (CDI), 30% was due to ischemic colitis, and 15% was due to non-specific colitis. Non-specific colitis was the most common (63%) in the community group. Clinical outcomes were also significantly different between both groups: higher mortality (10.0% vs. 0.64%, P=0.021), higher requirement for intensive care units care (50.0% vs. 18.8%, P<0.01) in LTCFs group. In univariate analysis, the most significant risk factor for death in patients in LTCFs was decreased mental faculties. CONCLUSIONS Patients in LTCFs showed worse clinical outcomes and a much higher prevalence of CDI compared to patients from local communities. We suggest early and active evaluation, such as endoscopic examination, for differential diagnosis in patients in LTCFs.
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Affiliation(s)
- So Yoon Yoon
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sung-Ae Jung
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sun-Kyung Na
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jae-In Ryu
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hye-Won Yun
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Min-Jin Lee
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Eun-Mi Song
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
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Jump RLP, Donskey CJ. Clostridium difficile in the Long-Term Care Facility: Prevention and Management. CURRENT GERIATRICS REPORTS 2015; 4:60-69. [PMID: 25685657 PMCID: PMC4322371 DOI: 10.1007/s13670-014-0108-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Residents of long-term care facilities are at high risk for Clostridium difficile infection due to frequent antibiotic exposure in a population already rendered vulnerable to infection due to advanced age, multiple comorbid conditions and communal living conditions. Moreover, asymptomatic carriage of toxigenic C. difficile and recurrent infections are prevalent in this population. Here, we discuss epidemiology and management of C. difficile infection among residents of long-term care facilities. Also, recognizing that both the population and culture differs significantly from that of hospitals, we also address prevention strategies specific to LTCFs.
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Affiliation(s)
- Robin L. P. Jump
- Geriatric Research Education and Clinical Center, Cleveland
Veterans Affairs Medical Center, Cleveland, Ohio
- Division of Infectious Diseases and HIV Medicine, Department of
Medicine, Case Western, Reserve University, Cleveland, Ohio
| | - Curtis J. Donskey
- Geriatric Research Education and Clinical Center, Cleveland
Veterans Affairs Medical Center, Cleveland, Ohio
- Division of Infectious Diseases and HIV Medicine, Department of
Medicine, Case Western, Reserve University, Cleveland, Ohio
- Research Service, Cleveland Veterans Affairs Medical Center,
Cleveland, Ohio
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Ziakas PD, Zacharioudakis IM, Zervou FN, Grigoras C, Pliakos EE, Mylonakis E. Asymptomatic carriers of toxigenic C. difficile in long-term care facilities: a meta-analysis of prevalence and risk factors. PLoS One 2015; 10:e0117195. [PMID: 25707002 PMCID: PMC4338134 DOI: 10.1371/journal.pone.0117195] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/19/2014] [Indexed: 11/29/2022] Open
Abstract
Background The impact of Clostridium difficile colonization in C. difficile infection (CDI) is inadequately explored. As a result, asymptomatic carriage is not considered in the development of infection control policies and the burden of carrier state in long-term care facilities (LTCFs) is unknown. Purpose To explore the epidemiology of C. difficile colonization in LTCFs, identify predisposing factors and describe its impact on healthcare management. Data Sources PubMed, Embase and Web of Science (up to June 2014) without language restriction, complemented by reference lists of eligible studies. Study Selection All studies providing extractable data on the prevalence of toxigenic C. difficile colonization among asymptomatic residents in LTCFs. Data Extraction Two authors extracted data independently. Statistical Methods The pooled colonization estimates were calculated using the double arcsine methodology and reported along with their 95% random-effects confidence intervals (CIs), using DerSimonian-Laird weights. We assessed the impact of patient-level covariates on the risk of colonization and effects were reported as odds ratios (OR, 95% CI). We used the colonization estimates to simulate the effective reproduction number R through a Monte Carlo technique. Results Based on data from 9 eligible studies that met the specified criteria and included 1,371 subjects, we found that 14.8% (95%CI 7.6%-24.0%) of LTCF residents are asymptomatic carriers of toxigenic C. difficile. Colonization estimates were significantly higher in facilities with prior CDI outbreak (30.1% vs. 6.5%, p = 0.01). Patient history of CDI (OR 6.07; 95% CI 2.06–17.88; effect derived from 3 studies), prior hospitalization (OR 2.11; 95% CI 1.08–4.13; derived from 3 studies) and antimicrobial use within previous 3 months (OR 3.68; 95% CI 2.04–6.62; derived from 4 studies) were associated with colonization. The predicted colonization rate at admission was 8.9%. Conclusion Asymptomatic carriage of toxigenic C. difficile represents a significant burden in LTCFs and is associated with prior CDI outbreaks in the facility, a history of CDI, prior hospitalization and antimicrobial use. These findings can impact infection control measures at LTCFs.
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Affiliation(s)
- Panayiotis D. Ziakas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
- * E-mail:
| | - Ioannis M. Zacharioudakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Fainareti N. Zervou
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Christos Grigoras
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Elina Eleftheria Pliakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
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Clostridium difficile ribotype 027 is most prevalent among inpatients admitted from long-term care facilities. J Hosp Infect 2014; 88:218-21. [PMID: 25228227 DOI: 10.1016/j.jhin.2014.06.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 06/27/2014] [Indexed: 01/05/2023]
Abstract
Intestinal inflammation was evaluated using faecal lactoferrin and ribotype in 196 hospitalized adults with Clostridium difficile infection to determine the impact of ribotype 027 in long-term care facilities (LTCFs). LTCF residents (n=28) had greater antibiotic use (P=0.049) and more ribotype 027 infection [odds ratio (OR): 4.87; 95% confidence interval (CI): 2.02-11.74; P<0.01], compared to those admitted from home. Patients infected with ribotype 027 strains had worse six-month mortality (OR: 1.90; 95% CI: 1.08-3.34; P=0.03) and more inflammation (95.26 vs 36.08 μg/mL; P=0.006), compared to those infected with non-027 strains. This study was not designed to determine acquisition site, but, in this population, suggests that the location from which the patient has been admitted is strongly associated with ribotype 027 and more severe C. difficile disease.
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Abstract
Clostridium difficile-associated illness is an increasingly prevalent and morbid condition. The elderly population is at a disproportionate risk of developing symptomatic disease and associated complications, including progression to severe or fulminant disease, and development of recurrent infections. This article analyzes the factors that influence C difficile disease propensity and severity, with particular attention directed toward features relevant to the rapidly aging population.
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Affiliation(s)
- Jonathan M Keller
- Department of Medicine, University of Washington Medical Center, 1959 Northeast Pacific Street, Box 356421, Seattle, WA 98195, USA
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Friedman HS, Navaratnam P, Reardon G, High KP, Strauss ME. A retrospective analysis of clinical characteristics, hospitalization, and functional outcomes in residents with and without Clostridium difficile infection in US long-term care facilities. Curr Med Res Opin 2014; 30:1121-30. [PMID: 24552133 DOI: 10.1185/03007995.2014.895311] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Patients in long-term care (LTC) are at increased risk for acquiring Clostridium difficile infection (CDI). We compared the characteristics and outcomes of matched cohorts with and without CDI in the LTC setting. METHODS Using a retrospective cohort design, demographic characteristics, Minimum Data Set (MDS 2.0) assessments (years 2007-2010), and pharmacy records of residents were analyzed. Residents were required to have a CDI diagnosis, ≥1 MDS 2.0 assessment ≤120 days pre- and post-index event, and receipt of metronidazole (MET) or vancomycin (VAN) within ±7 days of index date. Baseline characteristics were compared between cases and controls matched 1:3 on age, gender, and index year. Cox regression (CR) analysis evaluated the relationship between CDI status, and post-index mortality and hospitalization. RESULTS A total of 1145 CDI residents were matched with 3488 non-CDI residents. A second sample used propensity score methods. CDI vs. non-CDI residents had a higher baseline comorbidity burden (Charlson score: 3.0 ± 1.9 vs. 2.2 ± 1.8, respectively), and were more likely to have had a recent hospitalization (63% vs. 9%, respectively) and shorter mean pre-index continuous length of stay (cLOS) in the LTC (386.4 d ± 536.3 d vs. 568.3 d ± 567.4 d, respectively), all P < 0.0001. CR analyses of both samples indicated that CDI was strongly associated with shorter times to hospitalization and mortality (hazard ratio (HR) = 1.3, P = 0.023 and 2.2, P < 0.0001, respectively; propensity-matched group). Pre-index LTC cLOS also remained an important variable in the CR analysis and was the strongest predictor of post-index hospitalization and mortality (HR = 0.999 and 0.996, respectively, P < 0.0001), indicating that residents with longer pre-index LTC cLOS had longer times to post-index hospitalization and mortality. Our reliance on the MDS records for case identification was our chief limitation; misclassification was mitigated by our requirement to include CDI treatment as part of our inclusion criteria. CONCLUSIONS Understanding factors that put LTC patients at risk for CDI can help guide better management and improvement of patient outcomes.
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[Clostridium difficile infections in Spanish Internal Medicine departments during the period 2005-2010: the burden of the disease]. Enferm Infecc Microbiol Clin 2014; 33:16-21. [PMID: 24679445 DOI: 10.1016/j.eimc.2014.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 12/26/2013] [Accepted: 01/16/2014] [Indexed: 01/01/2023]
Abstract
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.
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Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infect Drug Resist 2014; 7:63-72. [PMID: 24669194 PMCID: PMC3962320 DOI: 10.2147/idr.s46780] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
There has been a startling shift in the epidemiology of Clostridium difficile infection over the last decade worldwide, and it is now increasingly recognized as a cause of diarrhea in the community. Classically considered a hospital-acquired infection, it has now emerged in populations previously considered to be low-risk and lacking the traditional risk factors for C. difficile infection, such as increased age, hospitalization, and antibiotic exposure. Recent studies have demonstrated great genetic diversity for C. difficile, pointing toward diverse sources and a fluid genome. Environmental sources like food, water, and animals may play an important role in these infections, apart from the role symptomatic patients and asymptomatic carriers play in spore dispersal. Prospective strain typing using highly discriminatory techniques is a possible way to explore the suspected diverse sources of C. difficile infection in the community. Patients with community-acquired C. difficile infection do not necessarily have a good outcome and clinicians should be aware of factors that predict worse outcomes in order to prevent them. This article summarizes the emerging epidemiology, risk factors, and outcomes for community-acquired C. difficile infection.
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Affiliation(s)
- Arjun Gupta
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Otete EH, Ahankari AS, Jones H, Bolton KJ, Jordan CW, Boswell TC, Wilcox MH, Ferguson NM, Beck CR, Puleston RL. Parameters for the mathematical modelling of Clostridium difficile acquisition and transmission: a systematic review. PLoS One 2013; 8:e84224. [PMID: 24376797 PMCID: PMC3869946 DOI: 10.1371/journal.pone.0084224] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/12/2013] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Mathematical modelling of Clostridium difficile infection dynamics could contribute to the optimisation of strategies for its prevention and control. The objective of this systematic review was to summarise the available literature specifically identifying the quantitative parameters required for a compartmental mathematical model of Clostridium difficile transmission. METHODS Six electronic healthcare databases were searched and all screening, data extraction and study quality assessments were undertaken in duplicate. Results were synthesised using a narrative approach. RESULTS Fifty-four studies met the inclusion criteria. Reproduction numbers for hospital based epidemics were described in two studies with a range from 0.55 to 7. Two studies provided consistent data on incubation periods. For 62% of cases, symptoms occurred in less than 4 weeks (3-28 days) after infection. Evidence on contact patterns was identified in four studies but with limited data reported for populating a mathematical model. Two studies, including one without clinically apparent donor-recipient pairs, provided information on serial intervals for household or ward contacts, showing transmission intervals of <1 week in ward based contacts compared to up to 2 months for household contacts. Eight studies reported recovery rates of between 75%-100% for patients who had been treated with either metronidazole or vancomycin. Forty-nine studies gave recurrence rates of between 3% and 49% but were limited by varying definitions of recurrence. No study was found which specifically reported force of infection or net reproduction numbers. CONCLUSIONS There is currently scant literature overtly citing estimates of the parameters required to inform the quantitative modelling of Clostridium difficile transmission. Further high quality studies to investigate transmission parameters are required, including through review of published epidemiological studies where these quantitative estimates may not have been explicitly estimated, but that nonetheless contain the relevant data to allow their calculation.
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Affiliation(s)
- Eroboghene H. Otete
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Anand S. Ahankari
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Helen Jones
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Kirsty J. Bolton
- Melbourne School of Population and Global Health , University of Melbourne, Melbourne, Australia
- School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Caroline W. Jordan
- NHS England Area Team Derbyshire, Nottingham and Nottinghamshire, United Kingdom
| | - Tim C. Boswell
- Department of Clinical Microbiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Mark H. Wilcox
- Department of Microbiology, University of Leeds, Leeds, United Kingdom
| | - Neil M. Ferguson
- School of Public Health, Imperial College London, London, United Kingdom
| | - Charles R. Beck
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Richard L. Puleston
- School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
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Garg S, Mirza YR, Girotra M, Kumar V, Yoselevitz S, Segon A, Dutta SK. Epidemiology of Clostridium difficile-associated disease (CDAD): a shift from hospital-acquired infection to long-term care facility-based infection. Dig Dis Sci 2013; 58:3407-12. [PMID: 24154638 DOI: 10.1007/s10620-013-2848-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 08/15/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Previous epidemiological studies on Clostridium-difficile-Associated Diarrhea (CDAD) have focused on hospitalized patients with nosocomial transmission. However, increasing numbers of patients with CDAD are being admitted to acute-care hospitals from long-term care facilities (LTCFs) and the local community. The purpose of our study was to study the changing epidemiological trends of CDAD patients admitted to an acute-care hospital and examine factors contributing to this shift in epidemiology. MATERIALS AND METHODS This IRB-approved retrospective study included 400 randomly selected patients with a diagnosis of CDAD, admitted to an acute-care hospital between January, 2005 and December, 2010. CDAD was defined as ≥3 episodes of loose stools in <24 h with a positive Clostridium difficile stool toxin assay. The patients were divided into three groups: hospital-acquired CDAD, long-term care facility (LTCF)-acquired CDAD, and community-acquired CDAD. The groups were compared in terms of demographics, ICU admissions, hospital length of stay, co-morbidities, presenting complaint, and medication use. Patients who were hospitalized in the preceding 12 weeks or who had history of antibiotic use in the prior 8 weeks were excluded. RESULTS Final analysis included 258 toxin-positive CDAD patients. Only 53 (20.6%) patients had hospital-acquired CDAD. Patients from LTCFs (n=119, 46.1%) and the community (86 patients, 33.3%) comprised 79.4% of patients. The mean age for LTCF population was significantly higher than the hospital-acquired and community-acquired CDAD groups (p<0.0001). The presenting complaint was categorized as diarrhea or non-diarrheal symptom. Other non-diarrheal symptoms included fever, abdominal pain and altered mental status. Only 15.2% of LTCF patients had diarrhea as their presenting complaint (n=18) as compared to 29.1% of patients from the community (n=25; p<0.05). Most LTCF patients (n=101, 84.8%) had non-diarrheal symptoms as their presenting complaint as compared to only 61 patients from the community (70.9%) (p<0.05). Use of proton pump inhibitor (PPI) was more frequent in LTCF patients (73%) and patients with hospital-acquired CDAD (69.8%) as compared to patients with community-acquired CDAD (43%) (p<0.05). No valid indication was found for PPI use in 24.13% of LTCF patients and 32.1% of patients with community-acquired CDAD as compared to only 12.9% of patients with hospital-acquired CDAD. CONCLUSION These observations suggest that CDAD originated predominantly in patients from LTCFs (46.1%) and community (33.3%) rather than from hospitalized patients (20.6%). Diarrhea was the presenting complaint in LTCF patients in only 15.2% of cases. Hence, CDAD should be suspected if LTCF patients present with symptoms such as abdominal pain, fever, or altered mental status along with loose stools. Majority of the LTCF patients were found to be on PPIs, a risk factor for CDAD, with as many as 24% of these patients with no valid indication for their use.
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Affiliation(s)
- Shashank Garg
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University, Sinai Hospital of Baltimore, Baltimore, MD, USA
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Marwick CA, Yu N, Lockhart MC, McGuigan CC, Wiuff C, Davey PG, Donnan PT. Community-associated Clostridium difficile infection among older people in Tayside, Scotland, is associated with antibiotic exposure and care home residence: cohort study with nested case-control. J Antimicrob Chemother 2013; 68:2927-33. [PMID: 23825381 DOI: 10.1093/jac/dkt257] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To estimate the risks of community-associated Clostridium difficile infection (CA-CDI) among the population aged ≥ 65 years associated with antibiotic exposure and care home residence. POPULATION AND METHODS We linked cases from a prospective study in Tayside, Scotland from 1 November 2008 to 31 October 2009 to population datasets to conduct a cohort study and a nested, matched (1 : 10 by age and gender) case-control study. RESULTS There were 79,039 eligible residents. CA-CDI incidence was 20.3/10,000 person years. In the cohort study, after adjustment, we found a significantly increasing risk of CA-CDI with increasing age and comorbidity, prior hospital admission, care home residence [hazard ratio (HR) 1.96, 95% CI 1.14-3.34] and baseline antibiotic exposure (1.94, 1.35-2.77). In separate adjusted models, '4C' antibiotics (clindamycin, co-amoxiclav, cephalosporins, ciprofloxacin; 2.75, 1.78-4.26) and fluoroquinolones (3.33, 1.95-5.67) had higher associated risks. We matched 62 CA-CDI cases without recent (prior 3 months) hospital admission to 620 controls. In adjusted logistic regression models, exposure to any antibiotics increased the risk of CA-CDI (OR 6.04, 95% CI 3.19-11.43). Exposure to 4C antibiotics or fluoroquinolones had higher associated risks: adjusted OR 11.60 (95% CI 5.57-24.15) and 13.04 (4.91-34.64), respectively. Risk of CA-CDI increased with cumulative antibiotic exposure. Subgroup analysis of 42 cases with C. difficile cultured and 420 controls amplified all associations between antibiotic exposure and CA-CDI. Care home residence independently increased the risk of CA-CDI in all models. CONCLUSIONS Our results have two important implications. First, they validate the classification of 4C antibiotics and fluoroquinolones in primary care as high risk for CA-CDI. Second, they demonstrate the importance of prior antibiotic exposure and place of residence for risk assessment by primary care prescribers.
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Affiliation(s)
- Charis A Marwick
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
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Arora V, Shah D, Garey K. Overview of Clostridium difficileInfection as an Emerging Health Care Facility–Acquired Infection. Hosp Pharm 2013. [DOI: 10.1310/hpj4802-s1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
PURPOSE OF REVIEW Clostridium difficile remains an important cause of infectious colitis, particularly in healthcare facilities. This review summarizes recent advances in the epidemiology, diagnosis, and treatment of this endemic pathogen. RECENT FINDINGS C. difficile infection (CDI) hospitalizations and mortality rates have increased over the last decade. The BI/NAP1/027 strain has been responsible for epidemics with increased severity and mortality and is now endemic in many settings, particularly North America. Concurrent antibiotics have now been shown to decrease the cure rates for anti-C. difficile therapy and increase the risk of recurrence. Although studies implicate proton pump inhibitors as a risk for CDI, the magnitude of and the biological basis for that risk remain unclear. Molecular diagnostic techniques are rapid and sensitive but highlight the importance of using appropriate clinical testing criteria. Fidaxomicin is a promising new therapy associated with decreased recurrence; infections due to BI strains, however, are associated with inferior outcomes regardless of the treatment agent. Fecal transplantation continues to have impressive success rates for patients with recurrent CDI, and a new colon-sparing surgical procedure presents an intriguing suggested alternative to total colectomy in severe, complicated cases. SUMMARY Elucidating CDI risk factors, identifying rapid, accurate diagnostic tools, and validating new treatment approaches remains an urgent priority.
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Mylotte JM, Russell S, Sackett B, Vallone M, Antalek M. Surveillance for Clostridium difficile infection in nursing homes. J Am Geriatr Soc 2012; 61:122-5. [PMID: 23253029 DOI: 10.1111/jgs.12041] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To define the time of onset of Clostridium difficile infection (CDI) in the community nursing home setting. DESIGN Retrospective. SETTING Four community nursing homes. PARTICIPANTS Residents with incident CDI identified from infection control surveillance records. MEASUREMENTS Cases were divided into two groups depending on the time of onset of infection: within 30 days of admission after hospitalization or more than 30 days after admission to a nursing home after hospitalization. RESULTS Of 75 incident CDI cases, 52 (69%) developed within 30 days of admission and 23 (31%) more than 30 days after admission. Of the 52 cases that developed within 30 days, 68% were in residents admitted for subacute care. The mean number of days ± standard deviation to CDI was 10.5 ± 2.5 in those who developed infection within 30 days; 75% of these cases developed within 15 days of admission. CONCLUSIONS The majority of CDI in the study nursing homes developed within 30 days of admission; this group may be analogous to community-onset, hospital-associated CDI as defined in the Centers for Disease Control and Prevention (CDC) surveillance definitions. Therefore, the proposed CDC surveillance definitions may overestimate the incidence of nursing home-associated CDI.
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Affiliation(s)
- Joseph M Mylotte
- Buffalo Geriatrics and Rehabilitation Medicine, Buffalo, New York, USA.
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Pawar D, Tsay R, Nelson DS, Elumalai MK, Lessa FC, Clifford McDonald L, Dumyati G. Burden of Clostridium difficile infection in long-term care facilities in Monroe County, New York. Infect Control Hosp Epidemiol 2012; 33:1107-12. [PMID: 23041808 DOI: 10.1086/668031] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Long-term care facility (LTCF) residents are at increased risk of Clostridium difficile infection (CDI). However, little is known about the incidence, recurrence, and severity of CDI in LTCFs or the extent to which acute care exposure contributes to CDI in LTCFs. We describe the epidemiology of CDI in a cohort of LTCF residents in Monroe County, New York, where recent estimates suggest a CDI incidence in hospitals of 9.2 cases per 10,000 patient-days. DESIGN Population-based surveillance study. SETTING Monroe County, New York. Patients. LTCF residents with onset of CDI while in the LTCF or less than 4 calendar-days after hospital admission from the LTCF from January 1 through December 31, 2010. METHODS We conducted surveillance for CDI in residents of 33 LTCFs. A CDI case was defined as a stool specimen positive for C. difficile obtained from a patient without a C. difficile-positive specimen in the previous 8 weeks; recurrence was defined as a stool specimen positive for C. difficile obtained between 2 and 8 weeks after the last C. difficile-positive stool specimen. RESULTS There were 425 LTCF-onset cases and 184 recurrences, which yielded an incidence of 2.3 cases per 10,000 resident-days (interquartile range [IQR], 1.2-3.3) and a recurrence rate of 1.0 case per 10,000 resident-days (IQR, 0.3-1.4). The cases occurred in 394 LTCF residents, and 52% of these residents developed CDI within 4 weeks after hospital discharge. Hospitalization for CDI occurred in 70 cases (16%). Of those cases that involved hospitalization for CDI, 70% were severe CDI, and 23% ended in death within 30 days after hospital admission. CONCLUSION CDI incidence in Monroe County LTCFs is one-fourth the incidence among hospitalized patients. Approximately 50% of LTCF-onset cases occurred more than 4 weeks after hospital discharge, which emphasizes that prevention of CDI transmission should go beyond acute care settings.
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Affiliation(s)
- Deepa Pawar
- Center for Community Health, University of Rochester, Rochester, New York, USA.
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McCollum DL, Rodriguez JM. Detection, treatment, and prevention of Clostridium difficile infection. Clin Gastroenterol Hepatol 2012; 10:581-92. [PMID: 22433924 DOI: 10.1016/j.cgh.2012.03.008] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 03/08/2012] [Accepted: 03/10/2012] [Indexed: 02/07/2023]
Abstract
Clostridium difficile is a gram-positive anaerobic bacillus responsible for approximately 1 of 5 cases of antibiotic-associated diarrhea. C difficile infection (CDI) is defined by at least 3 unformed stools in a 24-hour period and stool, endoscopic, or histopathologic test results that indicate the presence of this bacteria. The history of CDI research can be divided into early (before 2000) and modern eras (after 2000). C difficile was first described in 1935, and the characteristics and causes of CDI as well as therapies were identified during the early era of research. During the modern era, CDI has become a more common, aggressive nosocomial infection. Our understanding of the epidemiology, diagnosis, treatment, and prevention of CDI has increased at a rapid pace. We review features of CDI diagnosis, treatment, and prevention.
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Affiliation(s)
- David L McCollum
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama 35294-0006, USA
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Jinno S, Kundrapu S, Guerrero DM, Jury LA, Nerandzic MM, Donskey CJ. Potential for transmission of Clostridium difficile by asymptomatic acute care patients and long-term care facility residents with prior C. difficile infection. Infect Control Hosp Epidemiol 2012; 33:638-9. [PMID: 22561724 DOI: 10.1086/665712] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Sadao Jinno
- Department of Infectious Diseases, University Hospitals of Cleveland, Cleveland, Ohio, USA
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Vardakas KZ, Polyzos KA, Patouni K, Rafailidis PI, Samonis G, Falagas ME. Treatment failure and recurrence of Clostridium difficile infection following treatment with vancomycin or metronidazole: a systematic review of the evidence. Int J Antimicrob Agents 2012; 40:1-8. [PMID: 22398198 DOI: 10.1016/j.ijantimicag.2012.01.004] [Citation(s) in RCA: 199] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 01/04/2012] [Accepted: 01/05/2012] [Indexed: 12/30/2022]
Abstract
The objective of this review was to evaluate the frequency of treatment failure and recurrence of Clostridium difficile infection (CDI) following treatment with vancomycin or metronidazole in recently performed studies (last 10 years). Searches in PubMed and Scopus were performed by two reviewers independently. Data regarding treatment failure and recurrence following metronidazole and vancomycin treatment were extracted and analysed. In total, 39 articles (7005 patients) were selected for inclusion in the systematic review. The reported treatment failure was 22.4% with metronidazole (16 studies) and 14.2% with vancomycin (8 studies). Recurrence of CDI occurred in 27.1% of patients following metronidazole treatment (18 studies) and 24.0% of patients following vancomycin treatment (8 studies). Mean treatment failure and recurrence in the selected studies was 22.3% (24 studies) and 22.1% (37 studies). The reported outcomes depended on the study design (higher in prospective and retrospective cohort studies than in randomised controlled trials), geographic location of the study (higher in North America than in Europe and Asia), funding (higher in studies funded by non-profit organisations than pharmaceutical companies), mean age of the studied population (higher in older patients) and duration of follow-up (higher in studies with follow-up >1 month). In conclusion, infection with C. difficile is associated with 22.4% and 14.2% treatment failure and 27.1% and 24.0% recurrence after treatment with metronidazole and vancomycin, respectively. The variation in the reported outcomes amongst studies depends on the study design, location, funding, age and follow-up period.
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