1
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Kuenzli AB, Burri S, Casanova C, Sommerstein R, Buetti N, Seth-Smith HMB, Bodmer T, Egli A, Marschall J. Successful management of a Clostridioides difficile ribotype 027 outbreak with a lean intervention bundle. J Hosp Infect 2020; 106:240-245. [PMID: 32745592 DOI: 10.1016/j.jhin.2020.07.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/27/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND In a 2015 point-prevalence study, Clostridioides difficile 027, a hypervirulent ribotype, was absent from healthcare institutions in Switzerland. In late 2016, we detected an outbreak of C. difficile infection (CDI) with ribotype 027 occurring across several hospitals in the same hospital network. METHODS The first cases of CDI due to ribotype 027 triggered an outbreak investigation, including whole genome sequencing (WGS) to identify outbreak strains. FINDINGS Twenty-eight patients with CDI caused by ribotype 027 between December 2016 and December 2017 were identified, out of which 20 were caused by a single clone. Commonalities among these patients were hospitalization in the same room or on the same ward, receiving care from the same healthcare workers, and shared toilet areas. In addition to the epidemiological links suggesting possible transmission pathways between cases, WGS confirmed the clonality of this C. difficile 027 outbreak. The outbreak was contained by isolation precautions, raising awareness among healthcare workers, harmonizing diagnostic algorithms, and switching to a sporicidal agent for environmental disinfection. Of note, neither default gowning and gloving nor hand washing with water and soap were implemented. CONCLUSION This C. difficile 027 outbreak was recognized belatedly due to lack of screening for this ribotype in some hospitals, and was contained by a swift response with simple infection prevention measures and adapting the laboratory approach. In order to have a better understanding of C. difficile epidemiology, diagnostic approaches should be standardized, CDI declared notifiable, and longitudinal data on prevalent ribotypes collected in countries where this is not established.
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Affiliation(s)
- A B Kuenzli
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - S Burri
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - C Casanova
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - R Sommerstein
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - N Buetti
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; University of Paris, INSERM IAME, U1137, Team DesCID, Paris, France
| | - H M B Seth-Smith
- Division of Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland; Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - T Bodmer
- labormedizinisches zentrum Dr. Risch, Liebefeld, Switzerland
| | - A Egli
- Division of Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland; Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - J Marschall
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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2
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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: 150] [Impact Index Per Article: 30.0] [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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3
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The incidence and drug resistance of Clostridium difficile infection in Mainland China: a systematic review and meta-analysis. Sci Rep 2016; 6:37865. [PMID: 27897206 PMCID: PMC5126672 DOI: 10.1038/srep37865] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 10/20/2016] [Indexed: 12/18/2022] Open
Abstract
It has been widely reported that the incidence and severity of Clostridium difficile infection (CDI) have increased dramatically in North America and Europe. However, little is known about CDI in Mainland China. In this study, we aimed to investigate the incidence of CDI and the main epidemic and drug-resistant strains of C. difficile in Mainland China through meta-analysis of related studies published after the year 2010. A total of 51 eligible studies were included. The pooled incidence of toxigenic C. difficile among patients with diarrhoea was 14% (95% CI = 12–16%). In Mainland China, ST-37 and ST-3 were the most prevalent strains; fortunately, hypervirulent strains, such as ST-1 (BI/NAP1/027) and ST-11 (RT 078), have only occurred sporadically to date. The rates of C. difficile resistance to ciprofloxacin (98.3%; 95% CI = 96.9–99.7%), clindamycin (81.7%; 95% CI = 76.1–87.3%) and erythromycin (80.2%; 95% CI = 73.5–86.9%) are higher than in other counties; however, none of the C. difficile isolates reported in Mainland China were resistant to metronidazole (n/N = 0/960), vancomycin (n/N = 0/960), tigecycline (n/N = 0/41) or piperacillin/tazobactam(n/N = 0/288).
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4
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von Müller L, Mock M, Halfmann A, Stahlmann J, Simon A, Herrmann M. Epidemiology of Clostridium difficile in Germany based on a single center long-term surveillance and German-wide genotyping of recent isolates provided to the advisory laboratory for diagnostic reasons. Int J Med Microbiol 2015; 305:807-13. [PMID: 26341328 DOI: 10.1016/j.ijmm.2015.08.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Epidemiology of Clostridium difficile is characterized by worldwide increase of C. difficile infections (CDI) and the emergence of new epidemic outbreak strains with the capacity for global spreading. Long-term local surveillance at the University of Saarland Medical Center between 2000 and 2013 shows that the incidence rate of laboratory-confirmed CDI was influenced by local epidemiology as well as by testing strategies. Since 2008, molecular typing of C. difficile was regularly performed for symptomatic hospitalized patients by surface-layer protein A sequence typing (slpAST), which is an established highly standardized technique for genotyping of C. difficile. The results were assigned to known ribotypes for better comparison to international data. It could be demonstrated that distribution of genotypes was different between age groups. Older patients were predominantly infected with ribotype 001 and 027, whereas ribotype 027 was not detected in the pediatric population. Molecular typing of German isolates sent to the advisory laboratory between 2011 and 2013 revealed that ribotype 027 is present with high percentages in most German regions except for the very North. In conclusion, optimized testing of all hospitalized patients with diarrhea should be generally implemented to avoid under-diagnosis of C. difficile infection. Ribotype 027 is highly prevalent in Germany, but its infections are restricted to older patients, while absent in children. Molecular typing of suspected hospital outbreaks and of patients with severe or recurrent disease may help to better understand virulence and epidemic spreading of C. difficile.
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Affiliation(s)
- Lutz von Müller
- Institute of Medical Microbiology and Hygiene, State of Saarland Laboratory of Hygiene, Consultant Laboratory for Clostridium difficile, University of Saarland Medical Center, Kirrberger Straße, Building 43, Homburg D-66421 Saarland, Germany.
| | - Markus Mock
- Institute of Medical Microbiology and Hygiene, State of Saarland Laboratory of Hygiene, Consultant Laboratory for Clostridium difficile, University of Saarland Medical Center, Kirrberger Straße, Building 43, Homburg D-66421 Saarland, Germany
| | - Alexander Halfmann
- Institute of Medical Microbiology and Hygiene, State of Saarland Laboratory of Hygiene, Consultant Laboratory for Clostridium difficile, University of Saarland Medical Center, Kirrberger Straße, Building 43, Homburg D-66421 Saarland, Germany
| | - Julia Stahlmann
- Institute of Medical Microbiology and Hygiene, State of Saarland Laboratory of Hygiene, Consultant Laboratory for Clostridium difficile, University of Saarland Medical Center, Kirrberger Straße, Building 43, Homburg D-66421 Saarland, Germany
| | - Arne Simon
- Paediatric Hematology and Oncology, Children's Hospital Medical Center, University Hospital of Saarland, Kirrberger Straße, Building 9, Homburg, Saarland, Germany
| | - Mathias Herrmann
- Institute of Medical Microbiology and Hygiene, State of Saarland Laboratory of Hygiene, Consultant Laboratory for Clostridium difficile, University of Saarland Medical Center, Kirrberger Straße, Building 43, Homburg D-66421 Saarland, Germany
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5
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Daneman N, Guttmann A, Wang X, Ma X, Gibson D, Stukel TA. The association of hospital prevention processes and patient risk factors with the risk of Clostridium difficile infection: a population-based cohort study. BMJ Qual Saf 2015; 24:435-43. [PMID: 25911052 PMCID: PMC4484271 DOI: 10.1136/bmjqs-2014-003863] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 04/08/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Clostridium difficile is the most common cause of healthcare-acquired infection; the real-world impacts of some proposed C. difficile prevention processes are unknown. METHODS We conducted a population-based retrospective cohort study of all patients admitted to acute care hospitals between April 2011 and March 2012 in Ontario, Canada. Hospital prevention practices were determined by survey of infection control programmes; responses were linked to patient-level risk factors and C. difficile outcomes in Ontario administrative databases. Multivariable generalised estimating equation (GEE) regression models were used to assess the impact of selected understudied hospital prevention processes on the patient-level risk of C. difficile infection, accounting for patient risk factors, baseline C. difficile rates and structural hospital characteristics. RESULTS C. difficile infections complicated 2341 of 653 896 admissions (3.6 per 1000 admissions). Implementation of the selected C. difficile prevention practices was variable across the 159 hospitals with isolation of all patients at onset of diarrhoea reported by 43 (27%), auditing of antibiotic stewardship compliance by 26 (16%), auditing of cleaning practices by 115 (72%), on-site diagnostic testing by 74 (47%), vancomycin as first-line treatment by 24 (15%) and reporting rates to senior leadership by 52 (33%). None of these processes were associated with a significantly reduced risk of C. difficile after adjustment for baseline C. difficile rates, structural hospital characteristics and patient-level factors. Patient-level factors were strongly associated with C. difficile risk, including age, comorbidities, non-elective and medical admissions. CONCLUSIONS In the largest study to date, selected hospital prevention strategies were not associated with a statistically significant reduction in patients' risk of C. difficile infection. These prevention strategies have either limited effectiveness or were ineffectively implemented during the study period.
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Affiliation(s)
- N Daneman
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - A Guttmann
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - X Wang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - X Ma
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - D Gibson
- Health Analytics Branch, Ontario Ministry of Health and Long-Term Care, Toronto, Ontario, Canada
| | - TA Stukel
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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6
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Pereira JB, Farragher TM, Tully MP, Jonathan Cooke J. Association between Clostridium difficile infection and antimicrobial usage in a large group of English hospitals. Br J Clin Pharmacol 2015; 77:896-903. [PMID: 24868578 DOI: 10.1111/bcp.12255] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS This study aimed to determine the association between the reduction in the number of Clostridium difficile infection (CDI) cases reported by the English National Health Service (NHS) hospitals and concurrent antimicrobial use. METHODS A retrospective ecological study for January 2005 to December 2008 was conducted using data from 26 of the 29 NHS trusts (i.e. a trust manages one or more hospitals) located in the North West Strategic Health Authority of England. Antimicrobial use data, for patients of all ages, were provided by IMS Health, and CDI case data for patients aged ≥65 years were provided by the Health Protection Agency. Antimicrobial use was converted into defined daily doses (DDDs). The overall association between antimicrobial use and CDI for the trusts was investigated using multilevel models. RESULTS Our study shows a positive significant association between the CDI cases and the use of the following antimicrobials: ‘third-generation cephalosporins’ [11.62 CDI cases per 1000 DDDs; 95% confidence interval (CI), 5.92–17.31]; ‘fluoroquinolones’ (4.79 CDI cases per 1000 DDDs; 95% CI, 2.83–6.74); and ‘second-generation cephalosporins’ (4.25 CDI cases per 1000 DDDs; 95% CI, 1.66–6.83). The strength of this association was not significantly different (95% CI) among the antimicrobial groups. CONCLUSIONS This study shows that the reduction in the number of CDI cases reported by the English NHS hospitals is associated with concurrent reductions in antimicrobial use. This means that the number of CDI cases over time decreased in a similar fashion to the usage of various antimicrobials.
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7
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Lv Z, Peng GL, Su JR. Factors associated with Clostridium difficile diarrhea in a hospital in Beijing, China. ACTA ACUST UNITED AC 2014. [PMID: 25387676 PMCID: PMC4244675 DOI: 10.1590/1414-431x20143520] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Clostridium difficile is the most common cause of hospital-acquired
diarrhea in patients treated with antibiotics, chemotherapeutic agents, and other
drugs that alter the normal equilibrium of the intestinal flora. A better
understanding of the risk factors for C. difficile-associated
disease (CDAD) could be used to reduce the incidence of CDAD and the costs associated
with its treatment. The aim of this study was to identify the risk factors for CDAD
in a cohort of Chinese patients in a Beijing hospital. Medical charts of a total of
130 inpatients (62 males and 68 females) with hospital-acquired diarrhea (45 with
CDAD; 85 without CDAD) were retrospectively reviewed. C. difficile
toxins A and B were detected in fecal samples using enzyme-linked fluorescence
assays. The drugs used by patients with and without CDAD before the onset of diarrhea
were compared. Factors that differed significantly between the two groups by
univariate analysis were analyzed by multivariate analysis using a logistic
regression model. Multivariate analysis showed that cephalosporin treatment was
associated with a significantly higher risk of CDAD in hospitalized patients, while
treatment with glycopeptides was significantly associated with a reduction in CDAD
(P<0.001 for cephalosporin; P=0.013 for glycopeptides). Our data confirmed
previous findings that empirical treatment with cephalosporins is positively
associated with CDAD compared to individuals using other CDAD-related drugs.
Additionally, we showed that treatment with glycopeptides was negatively associated
with CDAD, compared to individuals using other CDAD-related drugs.
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Affiliation(s)
- Z Lv
- Clinical Laboratory Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - G L Peng
- Clinical Laboratory Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - J R Su
- Clinical Laboratory Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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8
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Vassallo A, Tran MCN, Goldstein EJC. Clostridium difficile: improving the prevention paradigm in healthcare settings. Expert Rev Anti Infect Ther 2014; 12:1087-102. [DOI: 10.1586/14787210.2014.942284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Angela Vassallo
- Department of Infection Prevention, Providence Saint John’s Health Center,
2121 Santa Monica Blvd, Santa Monica, CA 90404, USA
| | - Mai-Chi N Tran
- Department of Pharmacy, Providence Saint John’s Health Center,
2121 Santa Monica Blvd, Santa Monica, CA 90404, USA
| | - Ellie JC Goldstein
- Department of Infectious Diseases, Providence Saint John’s Health Center,
2121 Santa Monica Blvd, Santa Monica, CA 90404, USA
- The UCLA School of Medicine,
Los Angeles, CA 90073, USA
- The R M Alden Research Laboratory,
Santa Monica CA, 90404, USA
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9
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Sun C, Du P, Wu XR, Queener E, Shen B. Preoperative Clostridium difficile infection is not associated with an increased risk for the infection in ileal pouch patients. Dig Dis Sci 2014; 59:1262-8. [PMID: 24504594 DOI: 10.1007/s10620-014-3047-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/20/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) might contribute to a refractory course of pouchitis. However, the association between preoperative CDI and postoperative CDI in ileal pouch patients has not been investigated. AIM Our study aimed to evaluate whether preoperative CDI had an impact on the occurrence of postoperative CDI in pouch patients. METHODS Consecutive eligible ileal pouch patients from February 2005 to December 2012 were identified from the Pouchitis Registry at the Cleveland Clinic. Patients in the registry with known status of CDI of the pouch were surveyed with a structured questionnaire regarding preoperative C. difficile test and its treatment. Medical records were also reviewed. Demographics and clinical characteristics and outcomes were evaluated with univariable and multivariable analyses. RESULTS A total of 102 patients with preoperative C. difficile test were identified for this study and 21 patients (20.6%) tested positive for C. difficile test after colectomy. In logistic regression analysis, male patients were 7.85 (P = 0.003) times more likely to have CDI than women. In addition, preoperative significant comorbidities (P = 0.037) and preoperative use antibiotics for other indications (P = 0.005) were found to be associated with postoperative CDI of the pouch. However, there was no evidence to suggest that the preoperative CDI was associated with the occurrence of postoperative CDI (P = 0.769). CONCLUSIONS Postoperative CDI occurred frequently in male patients with IPAA. In addition, preoperative comorbidities and antibiotic use were found to be risk factors for CDI of the pouch. However, preoperative CDI did not appear to be associated with an increased risk for postoperative CDI in pouch patients.
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Affiliation(s)
- Chao Sun
- Department of Gastroenterology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
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10
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Pakyz AL, Jawahar R, Wang Q, Harpe SE. Medication risk factors associated with healthcare-associated Clostridium difficile infection: a multilevel model case-control study among 64 US academic medical centres. J Antimicrob Chemother 2013; 69:1127-31. [PMID: 24327619 DOI: 10.1093/jac/dkt489] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The main objective of this study was to determine patient- and hospital-level medication risk factors associated with Clostridium difficile infection (CDI) occurrence among patients clustered within hospitals using a multilevel model. METHODS Patients with healthcare-associated (HA)-CDI were identified from among 64 academic medical centres in 2009. A frequency match was conducted; for each case, up to two controls were selected, matched on similar pre-infection length of stay and clinical service line. Patient- and hospital-level medication use, including antibacterial and gastric acid-suppressant agents, was assessed using a two-level logistic regression model. RESULTS A total of 5967 CDI cases and 8167 controls were included in the analysis. The odds of acquiring HA-CDI increased with the following medications [OR (95% CI)]: anti-methicillin-resistant Staphylococcus aureus agents [1.38 (1.22-1.56)]; third- or fourth-generation cephalosporins [1.75 (1.62-1.89)]; carbapenems [1.60 (1.44-1.79)]; β-lactam/β-lactamase inhibitor combinations [1.49 (1.36-1.64)]; vancomycin [1.73 (1.57-1.89)]; and proton pump inhibitors [1.43 (1.30-1.57)]. The odds of acquiring HA-CDI decreased with the following medications: clindamycin [0.74 (0.63-0.87)]; and macrolides [0.88 (0.77-0.99)]. Controlling for patient-level covariates, no hospital-level medication covariates that we analysed had statistically significant effects on HA-CDI. The odds of acquiring HA-CDI increased with the hospital proportion of patients aged ≥ 65 years [1.01 (1.00-1.02)]. CONCLUSIONS We found several medications that were associated with the risk of patients developing HA-CDI, including β-lactam/β-lactamase inhibitor combinations, third- or fourth-generation cephalosporins, carbapenems, vancomycin, proton pump inhibitors and anti-methicillin-resistant S. aureus agents. There were no medication effects significant at the hospital level.
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Affiliation(s)
- Amy L Pakyz
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, VA, USA
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11
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Khanafer N, Touré A, Chambrier C, Cour M, Reverdy ME, Argaud L, Vanhems P. Predictors of Clostridium difficile infection severity in patients hospitalised in medical intensive care. World J Gastroenterol 2013; 19:8034-8041. [PMID: 24307797 PMCID: PMC3848151 DOI: 10.3748/wjg.v19.i44.8034] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/07/2013] [Accepted: 07/11/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To describe and analyse factors associated with Clostridium difficile infection (CDI) severity in hospitalised medical intensive care unit patients.
METHODS: We performed a retrospective cohort study of 40 patients with CDI in a medical intensive care unit (MICU) at a French university hospital. We include patients hospitalised between January 1, 2007 and December 31, 2011. Data on demographics characteristics, past medical history, CDI description was collected. Exposure to risk factors associated with CDI within 8 wk before CDI was recorded, including previous hospitalisation, nursing home residency, antibiotics, antisecretory drugs, and surgical procedures.
RESULTS: All included cases had their first episode of CDI. The mean incidence rate was 12.94 cases/1000 admitted patients, and 14.93, 8.52, 13.24, 19.70, and 8.31 respectively per 1000 admitted patients annually from 2007 to 2011. Median age was 62.9 [interquartile range (IQR) 55.4-72.40] years, and 13 (32.5%) were women. Median length of MICU stay was 14.0 d (IQR 5.0-22.8). In addition to diarrhoea, the clinical symptoms of CDI were fever (> 38 °C) in 23 patients, abdominal pain in 15 patients, and ileus in 1 patient. The duration of diarrhoea was 13.0 (8.0-19.5) d. In addition to diarrhoea, the clinical symptoms of CDI were fever (> 38 °C) in 23 patients, abdominal pain in 15 patients, and ileus in 1 patient. Prior to CDI, 38 patients (95.0%) were exposed to antibiotics, and 12 (30%) received at least 4 antibiotics. Fluoroquinolones, 3rd generation cephalosporins, coamoxiclav and tazocillin were prescribed most frequently (65%, 55%, 40% and 37.5%, respectively). The majority of cases were hospital-acquired (n = 36, 90%), with 5 cases (13.9%) being MICU-acquired. Fifteen patients had severe CDI. The crude mortality rate within 30 d after diagnosis was 40% (n = 16), with 9 deaths (9 over 16; 56.3%) related to CDI. Of our 40 patients, 15 (37.5%) had severe CDI. Multivariate logistic regression showed that male gender [odds ratio (OR): 8.45; 95%CI: 1.06-67.16, P = 0.044], rising serum C-reactive protein levels (OR = 1.11; 95%CI: 1.02-1.21, P = 0.021), and previous exposure to fluoroquinolones (OR = 9.29; 95%CI: 1.16-74.284, P = 0.036) were independently associated with severe CDI.
CONCLUSION: We report predictors of severe CDI not dependent on time of assessment. Such factors could help in the development of a quantitative score in ICU’s patients.
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12
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Wilcox MH, Shetty N, Fawley WN, Shemko M, Coen P, Birtles A, Cairns M, Curran MD, Dodgson KJ, Green SM, Hardy KJ, Hawkey PM, Magee JG, Sails AD, Wren MWD. Changing epidemiology of Clostridium difficile infection following the introduction of a national ribotyping-based surveillance scheme in England. Clin Infect Dis 2012; 55:1056-63. [PMID: 22784871 DOI: 10.1093/cid/cis614] [Citation(s) in RCA: 176] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Marked increases in Clostridium difficile infection (CDI) incidence, driven by epidemic strain spread, is a global phenomenon. METHODS The Clostridium difficile Ribotyping Network (CDRN) was established in 2007 as part of enhanced CDI surveillance in England, to facilitate the recognition and control of epidemic strains. We report on changes in CDI epidemiology in England in the first 3 years of CDRN. RESULTS CDRN received 12,603 fecal specimens, comprising significantly (P < .05) increasing numbers and proportions of national CDI cases in 2007-2008 (n = 2109, 3.8%), 2008-2009 (n = 4774, 13.2%), and 2009-2010 (n = 5720, 22.3%). The C. difficile recovery rate was 90%, yielding 11,294 isolates for ribotyping. Rates of 9 of the 10 most common ribotypes changed significantly (P < .05) during 2007-2010. Clostridium difficile ribotype 027 predominated, but decreased markedly from 55% to 36% and 21% in 2007-2008, 2008-2009, and 2009-2010, respectively. The largest regional variations in prevalence occurred for ribotypes 027, 002, 015, and 078. Cephalosporin and fluoroquinolone use in CDI cases was reported significantly (P < .05) less frequently during 2007-2010. Mortality data were subject to potential reporting bias, but there was a significant decrease in CDI-associated deaths during 2007-2010, which may have been due to multiple factors, including reduced prevalence of ribotype 027. CONCLUSIONS Access to C. difficile ribotyping was associated with significant changes in the prevalence of epidemic strains, especially ribotype 027. These changes coincided with markedly reduced CDI incidence and related mortality in England. CDI control programs should include prospective access to C. difficile typing and analysis of risk factors for CDI and outcomes.
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Affiliation(s)
- M H Wilcox
- Department of Microbiology, Old Medical School, Leeds General Infirmary, Thoresby Place, Leeds LS1 3EX, United Kingdom.
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Al-Obaydi W, Smith CD, Foguet P. Changing prophylactic antibiotic protocol for reducing Clostridium difficile-associated diarrhoeal infections. J Orthop Surg (Hong Kong) 2010; 18:320-3. [PMID: 21187543 DOI: 10.1177/230949901001800312] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To determine whether a change in prophylactic antibiotic protocol for orthopaedic surgeries may reduce the frequency of Clostridium difficile-associated diarrhoeal infections. METHODS Records of 1331 patients who underwent trauma or elective surgeries involving implantation of metalwork were reviewed. 231 trauma and 394 elective patients who received intravenous cefuroxime-based antibiotic prophylaxis between August 2006 and January 2007 were compared with 216 trauma and 490 elective patients who received a single dose of gentamicin and flucloxacillin or teicoplanin for antibiotic prophylaxis between August 2007 and January 2008. Diarrhoeal faecal specimens of 148 (33%) trauma patients and 106 (12%) elective patients were examined. The outcome variables were the rates of C difficile infection and early deep wound infection. RESULTS There were 32 cases of C difficile-associated diarrhoeal infection and 28 cases of early deep wound infection. The frequency of C difficile-associated diarrhoeal infection decreased after use of the new antibiotic protocol (from 4 to 1%, p = 0.004), particularly in the trauma patients (from 8 to 3%, p = 0.02); in the elective patients the difference was not significant (from 1 to 0.5%, p = 0.27). The change of antibiotic protocol did not significantly affect the incidence of deep wound infections in the trauma (p = 0.46) or elective (p = 0.90) patients. The rate of C difficile infection was 8-fold higher in the trauma than elective patients, both before and after the change of protocol. CONCLUSION Changing antibiotic protocol is one way of reducing the incidence of C difficile-associated diarrhoeal infections in orthopaedic patients, without increasing the rate of deep wound infections.
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Affiliation(s)
- Waleed Al-Obaydi
- Department of Orthopaedics, University Hospital Coventry and Warwickshire, Coventry, UK
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Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B, Kuijper EJ, Wilcox MH. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 2010; 33 Suppl 1:S42-5. [PMID: 20610822 DOI: 10.1016/s0924-8579(09)70016-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.
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Affiliation(s)
- J Freeman
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom
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Freeman J, Bauer MP, Baines SD, Corver J, Fawley WN, Goorhuis B, Kuijper EJ, Wilcox MH. The changing epidemiology of Clostridium difficile infections. Clin Microbiol Rev 2010; 23:529-49. [PMID: 20610822 PMCID: PMC2901659 DOI: 10.1128/cmr.00082-09] [Citation(s) in RCA: 619] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.
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Affiliation(s)
- J. Freeman
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - M. P. Bauer
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - S. D. Baines
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - J. Corver
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - W. N. Fawley
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - B. Goorhuis
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - E. J. Kuijper
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - M. H. Wilcox
- Department of Microbiology, Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, United Kingdom, Departments of Medical Microbiology and Infectious Diseases, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
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Nasereddin LM, Bakri FG, Shehabi AA. Clostridium difficile infections among Jordanian adult hospitalized patients. Am J Infect Control 2009; 37:864-6. [PMID: 19712999 DOI: 10.1016/j.ajic.2009.05.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Revised: 04/30/2009] [Accepted: 05/04/2009] [Indexed: 10/20/2022]
Abstract
This prospective study investigated the important epidemiologic aspects of Clostridium difficile infections (CDIs) among Jordanian adult hospitalized patients. A total of 300 stool specimens were investigated using culture and polymerase chain reaction methods for detection of C difficile, its toxins, and fluoroquinolone resistance. C difficile-positive cultures were found in 13.7% of the patients, and 73% of the isolates carried tcdA and/or tcdB toxin genes, and all C difficile isolates were negative for binary toxin. The isolates showed moderate level of resistance to both ciprofloxacin and levofloxacin, whereas metronidazole and vancomycin were highly susceptible. This study indicates the need for early detection of CDIs and prevention of its severe disease in hospitalized patients.
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Hardt C, Berns T, Treder W, Dumoulin FL. Univariate and multivariate analysis of risk factors for severe clostridium difficile-associated diarrhoea: Importance of co-morbidity and serum C-reactive protein. World J Gastroenterol 2008; 14:4338-41. [PMID: 18666322 PMCID: PMC2731185 DOI: 10.3748/wjg.14.4338] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate risk factors for severe clostridium difficile associated diarrhoea (CDAD) in hospitalized patients.
METHODS: We analysed risk factors for severe CDAD (associated with systemic signs of hypovolemia) in 124 hospitalized patients by retrospective chart review.
RESULTS: Severe CDAD was present in 27 patients (22%). Statistical analysis showed a significant association with a higher 30-d mortality (33% vs 4%, P < 0.001) and a higher proportion of longer hospital stay exceeding 14 d (74% vs 52%, P = 0.048). Charlson co-morbidity score (OR 1.29 for 1 point increment, P < 0.05) and serum C-reactive protein at diagnosis (OR 1.15 for 10 mg/L increment, P < 0.001) were independent predictors of severe CDAD.
CONCLUSION: Patients with a severe level of co-morbidity and high serum C-reactive protein levels at the time of diagnosis should receive particular attention.
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Affiliation(s)
- Ian R. Poxton
- Centre for Infectious Diseases, University of Edinburgh College of Medicine and Veterinary Medicine, The Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
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