Risk factors for severity and relapse of pseudomembranous colitis in an elderly population

Linked mutations within the pathogenicity locus of Clostridioides difficile increase virulence

BACKGROUND

The clinical manifestations of Clostridioides difficile infections range from diarrhoea to pseudomembranous colitis (PMC) and death. We evaluated the association between gene content in C. difficile clinical isolates and disease severity.

METHODS

Fifty-three C. difficile isolates were subjected to Sanger sequencing, clinical data were used to analyse the association of gene content with disease severity, and 83 non-duplicate isolates were collected to confirm the results. Virulence was further examined by functional in vitro and in vivo experiments.

RESULTS

Among the 53 C. difficile isolates, ribotypes 017 (n = 9, 17.0%) and 012 (n = 8, 15.1%) were predominant. Fifteen strains exhibited a correlation between mutations of pathogenicity locus genes (tcdB, tcdC, tcdR, and tcdE) and were named linked-mutation strains. Ribotypes are not associated with clinical PMC and Linked-mutation strains. The proportion of patients with PMC was higher in the group infected with linked-mutation strains than in the non-linked-mutation group (57.14% vs. 0%, p < 0.001). The linked-mutation rate of C. difficile was higher in patients with PMC than in patients without PMC (89.47% vs. 7.8%, p < 0.0001). Linked-mutation strains showed greater cytotoxicity in vitro and caused more severe tissue damage in a mouse model.

CONCLUSIONS

Linked-mutation strains are associated with high virulence and PMC development. This result will help monitor the clinical prognosis of C. difficile infection and provide key insights for developing therapeutic targets and monoclonal antibodies.

Metronidazole for Treatment of Clostridioides difficile Infections in Brazil: A Single-Center Experience and Risk Factors for Mortality

We describe the epidemiology of C. difficile infections (CDIs) focused on treatment and analyze the risk factors for mortality. This is a retrospective cohort study of CDI cases with a positive A/B toxin in the stool in 2017–2018. We analyzed the demographic data, comorbidities, previous use of antimicrobials, severity, and treatment, and we performed multivariate analysis to predict the 30-days mortality. We analyzed 84 patients, 37 (44%) of which were male, where the mean age was 68.1 years and 83 (99%) had comorbidities. The percentage of positivity of the A/B toxin was 11.6%, and the overall incidence density was 1.78/10,000 patient days. Among the patients, 65.4% had previous use of antimicrobials, with third-generation cephalosporins being the class most prescribed, and 22.6% of cases were severe. Treatment was prescribed for 70 (83.3%) patients, and there was no statistically significant difference between the initial treatment with metronidazole and vancomycin even in severe cases. The 30-day mortality was 7/84 (8.3%), and the risk factors associated with mortality was a severity score ≥2 (OR: 6.0; CI: 1.15–31.1; p = 0.03). In this cohort of CDI-affected patients with comorbidities and cancer, metronidazole was shown to be a good option for treating CDIs, and the severity score was the only independent risk factor for death.

Ulcerative Colitis in Adulthood and in Older Patients: Same Disease, Same Outcome, Same Risks?

The number of patients with inflammatory bowel disease (IBD) approaching an older age, together with the number of over-60-year-old patients newly diagnosed with IBD, is steadily increasing, reaching 25% of all patients. The present review focuses on late-onset ulcerative colitis (UC) and its initial disease course in comparison with that observed in younger adults in terms of extension at onset and the risk of proximal disease progression, medical treatment, surgery and hospitalization in the first years after diagnosis. We summarize the clues pointing to a milder disease course in a population which frequently presents major frailty due to comorbidities. With increasing age and thus increasing comorbidities, medical and surgical therapies frequently represent a challenge for treating physicians. The response, persistence, and risks of adverse events of conventional therapies indicated for late onset/older UC patients are examined, emphasizing the risks in this particular population, who are still being treated with prolonged corticosteroid therapy. Finally, we concentrate on data on biotechnological agents for which older patients were mostly excluded from pivotal trials. Real-life data from newer agents such as vedolizumab and ustekinumab show encouraging efficacy and safety profiles in the population of older UC patients.

Acid Suppression Medications During Hospitalization as a Risk Factor for Recurrence of Clostridioides difficile Infection: Systematic Review and Meta-analysis

BACKGROUND

Studies have had conflicting results regarding the influence of acid-suppression medications (ASMs) during hospitalization on the recurrence of Clostridioides difficile infection (CDI).

METHODS

A systematic review and meta-analysis investigating the association between recurrent CDI and ASM use in inpatients was performed. Relevant literature was identified using Medline, Google Scholar, and Web of Science. All human studies were considered regardless of publication date. Case-control and cohort studies and clinical trials were included if they contained the necessary information to calculate appropriate statistics related to the objective of this study. Review articles, meta-analyses, and commentaries were excluded; however, their references were searched to identify any studies missed. The random-effects model was selected since significant heterogeneity in study design was identified. To evaluate the sensitivity of the analysis various subgroup analyses were performed.

RESULTS

Our search identified 9 studies involving 5668 patients of whom 1003 (17.7%) developed recurrent CDI. Patients on ASM were 64% more likely to develop recurrent CDI than patients not on ASM (OR, 1.64; 95% CI, 1.13-2.38; P = .009; I2 = 79.54%). Proton pump inhibitor (PPI) use was associated with an 84% increased risk of recurrent CDI versus no ASM (OR, 1.84; 95% CI, 1.18-2.85; P = .007; I2 = 83.4%).

CONCLUSIONS

ASM use during hospitalization was associated with a 64% increase in recurrent CDI. The association was greater with PPI use. Due to significant heterogeneity in the analyses, additional studies are essential to further elucidate iatrogenic effects of ASM. Unnecessary PPI use should be discontinued.

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

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

Risk factors for poor outcome in community-onset Clostridium difficile infection

Background

A substantial portion of Clostridium difficile infection (CDI) cases occur in communities, and community-onset CDI (CO-CDI) can lead to serious complications including mortality. This study aimed to identify the risk factors for a poor outcome in CO-CDI.

Methods

We performed a retrospective review of all inpatients with CDI, in a 1300-bed tertiary-care hospital in Korea, from 2008 through 2015. CO-CDI was defined as CDI occurring within 48 h of admission. Poor outcome was defined as follows: 1) all-cause 30-day mortality, 2) in-hospital mortality, or 3) surgery due to CDI.

Results

Of a total 1256 CDIs occurring over 8 years, 152 (12.1%) cases were classified as CO-CDI and 23 (15.1%) had a poor outcome, including 22 (14.5%) cases of mortality and 2 (1.3%) cases of surgery. Patients with a poor outcome had a higher mean age than those without a poor outcome (75.8 vs. 69.6 years, p = 0.03). The proportion of men and prior proton pump inhibitor (PPI) use were significantly higher in the poor outcome group (65.2% vs. 41.9%, p = 0.04; 39.1% vs. 17.6%, p = 0.02, respectively). Multivariate binary logistic model showed that PPI use and anemia (hemoglobin < 10 g/dL) at presentation were significantly associated with a poor outcome (adjusted odds ratio [aOR], 3.76; 95% confidence interval [95CI], 1.26-11.21, aOR, 4.67; 95CI, 1.52-14.34, respectively).

Conclusions

Clinicians should not only be aware of the possibility of CDI in the community setting but also pay more attention to PPI-using elderly patients with anemia in consideration of a poor outcome.

Nasogastric tube and outcomes of Clostridium difficile infection: A systematic review and meta-analysis

AIMS

Clostridium difficile infection (CDI) is a major concern for public health worldwide. Interestingly, the risk of poor clinical outcomes of CDI in patients with nasogastric tube (NGT) insertion is still controversial. The aim of this study was to assess the outcomes of CDI in patients with NGT insertion.

METHODS

A literature search was performed using MEDLINE, EMBASE, and The Cochrane Database of Systematic Reviews from inception through November 2017. Studies that reported relative risks, odds ratios, or hazard ratios comparing the clinical outcome of CDI in patients with NGT versus those who did not were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Eight observational studies were included in our analysis to assess the association between NGT insertion and risk of poor outcome of CDI. The pooled RR of severe or complicated clinical outcomes of CDI in patients with NGT insertion was 1.81 (95% CI: 1.17 to 2.81).

CONCLUSIONS

This study demonstrated a statistically significant association between NGT insertion and risk of poor outcomes of CDI. This finding may impact clinical management and primary prevention of CDI. Avoidance of unnecessary NGT uses would improve the clinical outcomes of CDI.

Recent Issues in Pediatric Clostridium difficile Infection

PURPOSE OF REVIEW

We focus on two recent aspects of Clostridium difficile infection (CDI) in children, namely the emergence of community-associated CDI (CA-CDI) and the incidence and prevention of recurrent CDI.

RECENT FINDINGS

Current surveys suggest that a large proportion of all pediatric CDI is acquired in the community. Risk factors and frequency estimates of pediatric CA-CDI, however, are confounded in babies and toddlers by a high rate of asymptomatic excretion, whose detection likely is exaggerated by the wide use of highly sensitive nucleic acid amplification tests. Recurrent diarrhea occurs in up to 25% of children with CDI. Preventative strategies for recurrent CDI in adults, namely pulse and taper antibiotic dosing, use of anti-CDI drugs with mild effect on the colonic microbiome, fecal microbiota transplantation, and passive immune therapy, currently are being tested in children. Future studies are required to better characterize community acquisition of CDI in children and to define the safety and effectiveness of preventative strategies for recurrent CDI.

Association of Gastric Acid Suppression With Recurrent Clostridium difficile Infection: A Systematic Review and Meta-analysis

IMPORTANCE

Gastric acid suppression has been associated with an increased risk of primary Clostridium difficile infection (CDI), but the risk of recurrent CDI in patients taking gastric acid suppressant medications is unclear.

OBJECTIVE

To perform a systematic review and meta-analysis to evaluate the association between gastric acid suppressants and recurrent CDI.

DATA SOURCES

MEDLINE, EMBASE, the Cochrane Central Register, the Cochrane Database, and Web of Science were searched from January 1, 1995, to September 30, 2015, for studies assessing the association between gastric acid suppressant exposure and recurrent CDI. Search terms included Clostridium difficile, pseudomembranous colitis, proton pump inhibitor, and histamine H2 blocker.

STUDY SELECTION

Case-control studies, cohort studies, and clinical trials that included patients with CDI who did or did not receive gastric acid suppressant therapy and who were evaluated for recurrent CDI were included, with no restriction on study setting (inpatient or outpatient).

DATA EXTRACTION AND SYNTHESIS

The Newcastle-Ottawa scale was used to assess the methodologic quality of included studies. In this scale, case-control and cohort studies were scored on selection, comparability, and ascertainment of the outcome of interest. Data were independently abstracted to a predetermined collection form by 2 investigators. Summary odds ratio estimates with 95% CIs were calculated using the random-effects model and software to calculate the pooled effect size of studies reporting multivariate analyses.

MAIN OUTCOMES AND MEASURES

Risk of recurrent infection in patients with CDI and its association with use of gastric acid suppressant medication.

RESULTS

Sixteen observational studies were included, together reporting 7703 patients with CDI; among these, 1525 patients (19.8%) developed recurrent CDI. The rate of recurrent CDI in patients with gastric acid suppression was 22.1% (892 of 4038 patients) compared with 17.3% (633 of 3665) in patients without gastric acid suppression, which indicated an increased risk by meta-analysis (odds ratio [OR], 1.52; 95% CI, 1.20-1.94; P < .001). There was significant heterogeneity among the studies, with an I2 value of 64%. Subgroup analyses of studies adjusting for age and potential confounders confirmed an increased risk of recurrent CDI with use of gastric acid suppressants (OR, 1.38; 95% CI, 1.08-1.76; P = .02).

CONCLUSIONS AND RELEVANCE

Meta-analyses of observational studies suggest that patients who receive gastric acid suppressants may be at increased risk for recurrent CDI. These data should be interpreted with caution because they may be confounded owing to the observational design of the individual studies. It may be reasonable to re-evaluate the need for these medications in patients with CDI.

Role of the leukocyte response in normal and immunocompromised host after Clostridium difficile infection

Clostridium difficile is the leading cause of healthcare-associated infections in the United States. Clinically, C. difficile-associated disease can present as asymptomatic colonization, self-limited diarrheal illness or severe colitis (that may result in death). This variability in disease course and outcomes suggests that host factors play an important role as key determinants of disease severity. Currently, there are several scoring indices to estimate severity of C. difficile-associated disease. Leukocytosis and renal failure are considered to be the most important predictors of C. difficile disease severity in hosts with a normal immune system. The degree of leukocytosis which is considered significant for severe disease and how it is scored vary amongst scoring indices. None of the scores have been prospectively validated, and while total WBC count is useful to estimate the magnitude of the host response in most patient populations, in immune-compromised patients like those receiving chemotherapy, solid organ transplant patients or hematopoietic stem cell transplants the WBC response can be variable or even absent making this marker of severity difficult to interpret. Other cellular subsets like neutrophils, eosinophils and lymphocytes provide important information about the host immune status and play an important role in the immune response against C. difficile infection. However, under the current scoring systems the role of these cellular subsets have been underestimated and only total white blood cell counts are taken into account. In this review we highlight the role of host leukocyte response to C. difficile challenge in the normal and immunocompromised host, and propose possible ways that would allow for a better representation of the different immune cell subsets (neutrophils, lymphocytes and eosinophils) in the current scoring indices.

Body mass index greater than 35 is associated with severe Clostridium difficile infection

BACKGROUND

Obesity has been implicated in the acquisition of Clostridium difficile infections (CDI), however, no study has investigated whether there is a correlation between body mass index (BMI) and CDI severity.

AIM

To determine whether obesity, as measured by BMI correlates with severe hospital-onset or community-onset CDI.

METHODS

Patients admitted with CDI at a tertiary-care center from January 2013 to June 2015 were identified. The cohort was stratified by onset of disease using the National Healthcare Safety Network criteria, and by severity using the 2013 American College of Gastroenterology guidelines. Multivariate logistic regression was used to determine independent predictors of severe CDI.

RESULTS

A total of 196 met the inclusion criteria, of which 57.1% (112) met criteria for severe disease. Overall, BMI >35 kg/m² was 1.7-fold more likely to be associated with severe CDI compared to a BMI 20-35 kg/m² (P < 0.005), and was an independent predictor of severe CDI (P = 0.038). In patients with community-onset-CDI and hospital-onset-CDI, a BMI >35 kg/m² was associated with a 1.96-fold and 1.48 greater rate of severe CDI compared to a BMI 20-35 kg/m² (P = 0.004 and 0.048), and was an independent predictor of severe CDI in these cohorts (P = 0.039 and 0.027) respectively.

CONCLUSION

This study has identified an association between body mass index and Clostridium difficile infection severity. A BMI>35 kg/m² is an independent risk factor for severe community-onset and hospital-onset Clostridium difficile infections.

Medical versus Surgical Patients with Clostridium difficile Infection: Is There Any Difference?

Severity of Clostridium difficile infection (CDI) varies from one patient to another. We aimed to test the hypothesis that surgical patients would suffer more severe CDIs than medical patients. Patients receiving in-hospital medical or surgical treatment for any underlying disease from 2007 to 2012, who developed CDI, were divided into two groups: “Medical group” and “Surgical group.” Demographics, disease characteristics, and outcomes including mortality and recurrence were compared. Of 3231 patients with CDI evaluated, 1984 (61.4%) and 1247 (38.6%) were medical and surgical patients, respectively. Surgical patients had more severe CDIs than medical. However, the long-term effects of CDI were worse in medical patients, with more and quicker deaths. Recurrence was comparable between groups. Surgical patients were more frequently male, older, and obese; had higher white blood cells but lower levels of hemoglobin, hematocrit, and prealbumin; and had a higher rate of severe CDI. Conversely, medical patients had fewer in-hospital days, CDI appeared earlier, and had greater 30-day mortality and total number of deaths, with death after CDI occurring earlier. Although surgical patients tend to have a stormier clinical course related to CDI, overall they do better than medical patients. Future studies focusing on modifiable risk factors for each group are needed.

Clinical characteristics of Clostridium difficile-associated diarrhea among patients in a tertiary care center in China

Objective:

This study investigated the incidence, risk factors, and clinical characteristics of Clostridium difficile-associated diarrhea (CDAD) in Chinese patients.

Methods:

Fecal specimens of patients with antibiotic-associated diarrhea (AAD) were collected to test C. difficile toxin A and B using enzyme-linked fluorescent assay to identify CDAD. By adopting a nested case-control design, the matched people (ratio 1:3) without AAD were included as controls.

Results:

Out of 56,172 inpatients, 39,882 (71.0%) used antibiotics, 470 suffered from AAD, and 93 were diagnosed with CDAD. The incidence of nosocomial CDAD was 166 per 100,000. The proportion of CDAD in AAD was 19.8%. CDAD patients presented with more severe clinical manifestations and exhibited more concurrent illness. Logistic regression analysis showed the risk factors of CDAD: advanced age, nasogastric tube-feeding, high APACHE II scores, high level of serum C-reaction protein, low level of serum albumin, severe underlining disease or comorbidity, and number of antibiotic intake. Twenty-nine patients (31.2%) were cured with vancomycin, 54 (58.1%) were cured after dual therapy of vancomycin plus metronidazole, 7 (7.5%) died of underlying diseases aggravated with CDAD, and 3 (3.2%) were transferred to other hospitals for personal reasons.

Conclusion:

The incidence of nosocomial CDAD in China was high. Some risk factors could predispose CDAD.

The risk of Clostridium difficile associated diarrhea in nasogastric tube insertion: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Clostridium difficile-associated diarrhea (CDAD) is a major concern of public health worldwide. The risk of CDAD in patients with nasogastric tube (NGT) insertion is controversial. The aim of this study was to assess the risk of incidence of CDAD in patients with NGT insertion.

METHODS

A literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from inception through August 2015. Studies that reported relative risks, odds ratios, or hazard ratios comparing the risk of CDAD in patients with NGT insertion versus those who did not were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Eleven observational studies were included in our analysis to assess the association between NGT insertion and risk of CDAD. The pooled RR of CDAD in patients with NGT insertion was 1.87 (95% CI, 1.06-3.28, I(2)=73). When meta-analysis was limited only to cohort and case-control studies, the pooled RR of CDAD was 1.99 (95% CI, 1.05-3.77, I(2)=76).

CONCLUSIONS

Our study demonstrated a statistically significant association between NGT insertion and risk of CDAD. This finding may impact clinical management and primary prevention of CDAD.

Factors Predicting Recurrence of Clostridium difficile Infection (CDI) in Hospitalized Patients: Retrospective Study of More Than 2000 Patients

BACKGROUND

Clostridium difficile infection (CDI) has increased in incidence and severity worldwide, causing direct costs estimated to range from US $3.2 billion to $4.8 billion. The aim of this study was to investigate and identify factors that predict recurrence of CDI.

METHODS

This was a retrospective case-control study between 2007 and 2013 on patients admitted with CDI. Recurrent CDI is defined as a new episode of diarrhea within 90 days confirmed by a positive stool C. difficile toxin assay or polymerase chain reaction, after resolution of the initial CDI episode for at least 10 days and after discontinuation of the CDI therapy.

RESULTS

Three thousand twenty patients were diagnosed with CDI between January 2007 and December 2013. Two hundred nine of 2019 patients in the study had a recurrence of CDI within 90 days of the end of the initial CDI episode (10.3%). Multivariate analysis showed that most of the recurrences occurred in patients with comorbidities, particularly chronic kidney disease (odds ratio, 1.3; 95% confidence interval [CI], 1.0-2.4; P = 0.039). In addition, a higher percentage of patients in the recurrence group were prescribed proton-pump inhibitors (odds ratio, 1.65; 95% CI, 1.0-1.7; P = 0.002) and steroids (odds ratio, 1.65; 95% CI, 1.0-1.5; P = 0.047).

CONCLUSIONS

Our data suggest that the use of glucocorticoids, use of proton-pump inhibitors, and having end-stage renal disease are significant risk factors associated with recurrent CDI.

Outcomes of Recurrent Rectal Cancer after Transanal Excision

Successful surgical salvage after transanal excision (TAE) of rectal cancers has historically been considered feasible, but results vary. We examine our experience in surgical salvage of locally recurrent rectal cancers after TAE. A retrospective review of patients undergoing salvage surgery for locally recurrent early-stage rectal cancer after TAE from March 1990 to March 2008 at our institution is presented here. Seventy-eight patients underwent TAE for tumor invades submucosa (T1) rectal cancer. Average age of patients was 68.3 years. Recurrence occurred in 17 patients (21.8%). Median number of months between the first operation and the recurrence was 41 months. Sixteen out of 17 patients recurred locally whereas one had only distant recurrence. Fourteen were eligible for surgical salvage. Ten patients underwent abdominoperineal resection, whereas four underwent repeat local excision. Eleven deaths were noted and the median survival after the first operation was 70.3 months. Disease-free survival after salvage surgery was 53 per cent (9/17), with a median follow-up of 68 months from the original surgery. Disease-specific mortality was 47 per cent (8/17), with a median survival of 72 months from the original surgery. Five-year survival in the recurrence group was 11/16 (69%). In conclusion, TAE for T1 rectal cancer carries a higher risk of recurrence. Of the local recurrences, 87.5 per cent underwent microscopic negative margins (R0) resection at the time of salvage and had a five-year survival of 69 per cent. Long-term surveillance is encouraged, as recurrence can be seen even after 10 years from initial treatment. TAE can be considered for T1 rectal tumor with reasonable outcomes.

Recurrent Clostridium difficile infection: From colonization to cure

Clostridium difficile infection (CDI) is increasingly prevalent, dangerous and challenging to prevent and manage. Despite intense national and international attention the incidence of primary and of recurrent CDI (PCDI and RCDI, respectively) have risen rapidly throughout the past decade. Of major concern is the increase in cases of RCDI resulting in substantial morbidity, morality and economic burden. RCDI management remains challenging as there is no uniformly effective therapy, no firm consensus on optimal treatment, and reliable data regarding RCDI-specific treatment options is scant. Novel therapeutic strategies are critically needed to rapidly, accurately, and effectively identify and treat patients with, or at-risk for, RCDI. In this review we consider the factors implicated in the epidemiology, pathogenesis and clinical presentation of RCDI, evaluate current management options for RCDI and explore novel and emerging therapies.

What's the Clinical Features of Colitis in Elderly People in Long-Term Care Facilities?

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.

Attributable inpatient costs of recurrent Clostridium difficile infections

OBJECTIVE

To determine the attributable inpatient costs of recurrent Clostridium difficile infections (CDIs).

DESIGN

Retrospective cohort study.

SETTING

Academic, urban, tertiary care hospital.

PATIENTS

A total of 3,958 patients aged 18 years or more who developed an initial CDI episode from 2003 through 2009.

METHODS

Data were collected electronically from hospital administrative databases and were supplemented with chart review. Patients with an index CDI episode during the study period were followed up for 180 days from the end of their index hospitalization or the end of their index CDI antibiotic treatment (whichever occurred later). Total hospital costs during the outcome period for patients with recurrent versus a single episode of CDI were analyzed using zero-inflated lognormal models.

RESULTS

There were 421 persons with recurrent CDI (recurrence rate, 10.6%). Recurrent CDI case patients were significantly more likely than persons without recurrence to have any hospital costs during the outcome period (P < .001). The estimated attributable cost of recurrent CDI was $11,631 (95% confidence interval, $8,937-$14,588).

CONCLUSIONS

The attributable costs of recurrent CDI are considerable. Patients with recurrent CDI are significantly more likely to have inpatient hospital costs than patients who do not develop recurrences. Better strategies to predict and prevent CDI recurrences are needed.

The roles of host and pathogen factors and the innate immune response in the pathogenesis of Clostridium difficile infection

Clostridium difficile (C. difficile) is the most common cause of nosocomial antibiotic-associated diarrhea and the etiologic agent of pseudomembranous colitis. The clinical manifestation of C. difficile infection (CDI) is highly variable, from asymptomatic carriage, to mild self-limiting diarrhea, to the more severe pseudomembranous colitis. Furthermore, in extreme cases, colonic inflammation and tissue damage can lead to toxic megacolon, a condition requiring surgical intervention. C. difficile expresses two key virulence factors; the exotoxins, toxin A (TcdA) and toxin B (TcdB), which are glucosyltransferases that target host-cell monomeric GTPases. In addition, some hypervirulent strains produce a third toxin, binary toxin or C. difficile transferase (CDT), which may contribute to the pathogenesis of CDI. More recently, other factors such as surface layer proteins (SLPs) and flagellin have also been linked to the inflammatory responses observed in CDI. Although the adaptive immune response can influence the severity of CDI, the innate immune responses to C. difficile and its toxins play crucial roles in CDI onset, progression, and overall prognosis. Despite this, the innate immune responses in CDI have drawn relatively little attention from clinical researchers. Targeting these responses may prove useful clinically as adjuvant therapies, especially in refractory and/or recurrent CDI. This review will focus on recent advances in our understanding of how C. difficile and its toxins modulate innate immune responses that contribute to CDI pathogenesis.

Clinical predictors of recurrent Clostridium difficile infection in out-patients

BACKGROUND

Clostridium difficile infection (CDI) recurs in 20-30% of patients.

AIM

To describe the predictors of recurrence in out-patients with CDI.

METHODS

Out-patient cases of CDI in Olmsted County, MN residents diagnosed between 28 June 2007 and 25 June 2010 were identified. Recurrent CDI was defined as recurrence of diarrhoea with a positive C. difficile PCR test from 15 to 56 days after the initial diagnosis with interim resolution of symptoms. Patients who had two positive tests within 14 days were excluded. Cox proportional hazard models were used to assess the association of clinical variables with time to recurrence of CDI.

RESULTS

The cohort included 520 out-patients; 104 had recurrent CDI (cumulative incidence of 17.5% by 30 days). Univariate analysis identified increasing age and antibiotic use to be associated with recurrent CDI. Severe CDI, peripheral leucocyte count and change in serum creatinine >1.5-fold were not. In a multiple variable model, concomitant antibiotic use was associated with risk of recurrent CDI (HR = 5.4, 95% CI 1.6-17.5, P = 0.005), while age (HR per 10 year increase = 1.1, 95% CI 0.9-1.3, P = 0.22); peripheral leucocyte count >15 × 10(9) /L (HR = 1.0, 95% CI 0.5-2.1, P = 0.92); and change in serum creatinine greater than 1.5-fold (HR = 0.8, 95% CI 0.4-1.5, P = 0.44) were not.

CONCLUSIONS

Antibiotic use was independently associated with a dramatic risk of recurrent Clostridium difficile infection in an out-patient cohort. It is important to avoid unnecessary systemic antibiotics in patients with Clostridium difficile infection, and patients with ongoing antibiotic use should be monitored closely for recurrent infection.

The host immune response to Clostridium difficile infection

Clostridium difficile infection (CDI) is the most common infectious cause of healthcare-acquired diarrhoea. Outcomes of C. difficile colonization are varied, from asymptomatic carriage to fulminant colitis and death, due in part to the interplay between the pathogenic virulence factors of the bacterium and the counteractive immune responses of the host. Secreted toxins A and B are the major virulence factors of C. difficile and induce a profound inflammatory response by intoxicating intestinal epithelial cells causing proinflammatory cytokine release. Host cell necrosis, vascular permeability and neutrophil infiltration lead to an elevated white cell count, profuse diarrhoea and in severe cases, dehydration, hypoalbuminaemia and toxic megacolon. Other bacterial virulence factors, including surface layer proteins and flagella proteins, are detected by host cell surface signal molecules that trigger downstream cell-mediated immune pathways. Human studies have identified a role for serum and faecal immunoglobulin levels in protection from disease, but the recent development of a mouse model of CDI has enabled studies into the precise molecular interactions that trigger the immune response during infection. Key effector molecules have been identified that can drive towards a protective anti-inflammatory response or a damaging proinflammatory response. The limitations of current antimicrobial therapies for CDI have led to the development of both active and passive immunotherapies, none of which have, as yet been formally approved for CDI. However, recent advances in our understanding of the molecular basis of host immune protection against CDI may provide an exciting opportunity for novel therapeutic developments in the future.

Risk Factors for Relapse and Mortality of Clostridium Difficile-Associated Diarrhea

AIM: The aim of the present paper was to identify prognostic factors for relapse and mortality in patients with hospital-acquired infections caused by Clostridium difficile.MATERIAL AND METHODS: This study included 133 patients with healthcare facility-associated disease caused by C. difficile. The medical records of all patients with their clinical history and laboratory data were analyzed.RESULTS: Patients with one onset of disease were 105 (78.9%), 28 (21.1%) experienced a relapse and seven (5.2%) patients not survived infection. The average age in our patients was over 65 years (64.5 years in the survived patients and 78.8 in patient who died, p = 0.01). All of patients had received antibiotic treatment (cephalosporins – 83.4%, aminoglycosides – 21.5% and penicillins – 20.3%) and 40.6% of patients received acid-reducing therapy. There was no difference between patients with one onset of disease/patients with relaps; and survived/died in number of administered antibiotics, duration of administration, administration of acid-reducing treatment or length of hospital stay (p > 0.05). CRP levels were significantly higher in the group of patients who died compared with recovered (p < 0.001). CONCLUSION:  C. difficile-associated diarrhea is a common nosocomial disease with high relapse, and significant mortality rate particularly in the elderly.

Community-acquired Clostridium difficile infection: an increasing public health threat

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.

Is obesity a risk factor for Clostridium difficile infection?

BACKGROUND

The epidemiology of Clostridium difficile infection (CDI) has become an important area of investigation, especially in light of the global increase in both hospital-acquired (HA) and community-acquired (CA) CDI. Recently, obesity was found to be associated with CDI and was suggested to represent an independent risk factor for it.

OBJECTIVE

We undertook a case-control study to examine obesity as an exposure for both HA and CA cases in adults (age ≥ 18 years) admitted to a tertiary, university-affiliated, acute care medical facility in the northeastern United States.

METHODS

During the period January 2012-July 2013, we examined cross-sectional BMI data on 189 cases of CDI and 189 contemporaneous age and gender-matched controls.

RESULTS

We were unable to detect a statistically significant difference between the two groups; in fact, the BMI values for both groups were substantially equivalent (cases: median=26.5 kg/m, IQR: 22.1-32.5; controls: median=26.0, IQR: 22.7-31.0; p=0.696). Odds ratios (and 95% confidence intervals), evaluated at BMI of 25, 30 and 35 kg/m(2), did not demonstrate statistical significance.

CONCLUSION

These data suggest that obesity, as described by BMI, may not be a risk factor for CDI in all populations.

Using syndromic surveillance to estimate baseline rates for healthcare-associated infections in critical care units of small animal referral hospitals

BACKGROUND

Expected rates of healthcare-associated infections (HCAI) have not been established in veterinary hospitals. Baseline rates are critically needed as benchmarks for quality animal care.

OBJECTIVE

To estimate the occurrence of events related to HCAI identified using a standardized syndromic surveillance system in small animals in critical care cases at referral hospitals.

ANIMALS

Weaned dogs and cats (n = 1,951) that were hospitalized in the critical care unit of referral teaching hospitals during a 12-week period.

METHODS

Multicenter, prospective longitudinal study. A survey was completed for all enrolled animals to record basic demographics, information about procedures and treatments that animals received, and to document the occurrence of defined nosocomial syndromes. Data were analyzed to identify risk factors associated with the occurrence of these nosocomial syndromes.

RESULTS

Controlling for hospital of admission, 16.3% of dogs (95% confidence intervals [CI], 14.3-18.5) and 12% of cats (95% CI, 9.3-15.5) were reported to have had ≥ 1 nosocomial syndrome occur during hospitalization. Risk factors found to have a positive association with the development of a nosocomial syndrome were longer hospital stays, placement of a urinary catheter, surgical procedures being performed, and the administration of antiulcer medications and antimicrobial drugs excluding those given perioperatively.

CONCLUSIONS AND CLINICAL IMPORTANCE

Syndromic surveillance systems can be successfully standardized for use across multiple hospitals to effectively collect data pertinent to HCAI rates and risk factors for occurrence.

Clostridium difficile infection in children: a comprehensive review

OBJECTIVE

To provide a comprehensive review of the literature relating to Clostridium difficile (C. difficile) infection (CDI) in the pediatric population.

METHODS

Two investigators conducted independent searches of PubMed, Web of Science, and Scopus until March 31st, 2013. All databases were searched using the terms 'Clostridium difficile infection', 'Clostridium difficile associated diarrhea' 'antibiotic associated diarrhea', 'C. difficile', in combination with 'pediatric' and 'paediatric'. Articles which discussed pediatric CDI were reviewed and relevant cross references also read and evaluated for inclusion. Selection bias could be a possible limitation of this approach.

FINDINGS

There is strong evidence for an increased incidence of pediatric CDI. Increasingly, the infection is being acquired from the community, often without a preceding history of antibiotic use. The severity of the disease has remained unchanged. Several medical conditions may be associated with the development of pediatric CDI. Infection prevention and control with antimicrobial stewardship are of paramount importance. It is important to consider the age of the child while testing for CDI. Traditional therapy with metronidazole or vancomycin remains the mainstay of treatment. Newer antibiotics such as fidaxomicin appear promising especially for the treatment of recurrent infection. Conservative surgical options may be a life-saving measure in severe or fulminant cases.

CONCLUSIONS

Pediatric providers should be cognizant of the increased incidence of CDI in children. Early and judicious testing coupled with the timely institution of therapy will help to secure better outcomes for this disease.

Is colectomy for fulminant Clostridium difficile colitis life saving? A systematic review

AIM

It is unclear whether colectomy for fulminant Clostridium difficile colitis (FCDC) leads to a improvement in survival compared with continued medical therapy for this moribund population.

METHOD

Selected studies from 1994-2010 were identified through a comprehensive search theme applied to MEDLINE (OvidSP and PubMed), EMBASE and by hand searching. Data regarding mortality rates between medically and surgically treated patients were extracted. Risk of bias was assessed using a Newcastle-Ottawa Scale score. A meta-analysis of the odds ratios for mortality between surgical and medical treatment for FCDC was conducted using the Mantel-Haenszel method and fixed-effects modelling.

RESULTS

Five hundred and ten patients with FCDC were identified in six studies. The pooled adjusted odds ratio of mortality comparing surgery with medical therapy was 0.70 (0.49-0.99), suggesting that surgery provided a survival benefit.

CONCLUSION

Emergent colectomy for patients with FCDC provides a survival advantage compared with continuing antibiotics. Though there is selection bias of patients having surgery, the results of this systematic review suggest that colectomy has a therapeutic role in treating severe forms of C. difficile colitis.

The impact of pseudomembrane formation on the outcome of Clostridium difficile-associated disease

PURPOSE

Although pseudomembranes are the hallmark manifestation of Clostridium difficile-associated diarrhea (CDAD), there are scant data specifically addressing their impact on the clinical outcome. We investigated whether the formation of pseudomembranes predicts a worse CDAD outcome.

METHODS

CDAD patients hospitalized during 2010 underwent sigmoidoscopy and were followed prospectively. In addition, all hospitalized CDAD patients in the period 01/2000-12/2009 who underwent lower endoscopy were retrospectively identified and their charts reviewed. Patients with detectable pseudomembranes on endoscopy were compared to those in whom pseudomembranes were absent. Thirty-day mortality and a composite outcome comprised of mortality within 30 days of diagnosis, admission to the intensive care unit (ICU), colectomy, peritonitis, hemodynamic instability, or respiratory insufficiency were addressed. Additional clinical outcomes used for comparison between the two groups were 60-day mortality, duration of hospitalization, and the failure of metronidazole and vancomycin.

RESULTS

A total of 117 CDAD patients (mean age 62.9 ± 19 years) who underwent lower endoscopy were included; 46 with pseudomembranes and 71 without. Seven out of the 46 patients with pseudomembranes died within 30 days compared to 9/71 in the non-pseudomembrane group [odds ratio (OR) 1.2, 95% confidence interval (CI) 0.4-3.6, P = 0.8]. Similarly, there was no correlation between the occurrence of pseudomembranes and the rate of the composite adverse outcome (P = 0.6). In contrast, acute renal insufficiency (OR 15, 95% CI 3.2-72, P < 0.001) and hypoalbuminemia (OR 5.7, 95% CI 1.8-18, P = 0.002) were both independently predictive of a severe clinical outcome.

CONCLUSIONS

Our findings suggest that the presence of pseudomembranes is not associated with an adverse outcome in CDAD patients.

Pseudomembranous colitis within radiotherapy field following concurrent chemoradiation therapy: a case report

Development of nonantibiotic-associated pseudomembranous colitis has been reported in patients receiving chemotherapy. Herein, we report a case of a 70-year-old man with diabetes mellitus and hypertension who received concurrent chemoradiation therapy after surgery for stage III pT3N1M0 rectal cancer. After completion of the therapy, the patient presented with a 2-week history of intermittent watery diarrhea (seven to nine times per day). However, the patient was afebrile and laboratory examination revealed no evidence of leukocytosis. Computed tomography disclosed inflammation of the sigmoid colon, infiltrative changes around the anastomotic site, and edematous changes straddling the serosal surface. Colonoscopic examination revealed multiple whitish patches within the radiation field, a finding suggestive of pseudomembranous colitis. No concomitant antibiotics were used during the period of concurrent chemoradiation therapy. Empirical oral metronidazole (500 mg every 8 hours) was administrated for 2 weeks. At the end of this treatment, stool culture was negative for Clostridium difficile. Physicians should be aware of the potential for the development of pseudomembranous colitis following concurrent chemoradiation therapy.

Renal failure and leukocytosis are predictors of a complicated course of Clostridium difficile infection if measured on day of diagnosis

Nonsevere Clostridium difficile infection (CDI) and severe CDI, which carries a higher risk than nonsevere CDI for treatment failure and CDI recurrence, are difficult to distinguish at the time of diagnosis. To investigate the prognostic value of 3 markers of severe CDI suggested by recent guidelines (fever, leukocytosis, and renal failure), we used the database of 2 randomized controlled trials, which contained information for 1105 patients with CDI. Leukocytosis (risk ratio [RR], 2.29; 95% confidence interval [CI], 1.63–3.21) and renal failure (RR, 2.52; 95% CI, 1.82–3.50) were associated with treatment failure. Fever, although associated with treatment failure (RR, 2.45; 95% CI, 1.07–5.61), was rare. Renal failure was the only significant predictor of recurrence (RR, 1.45; 95% CI, 1.05–2.02). Different timing of measurements of leukocyte count and serum creatinine level around the CDI diagnosis led to a different severity classification in many cases. In conclusion, both leukocytosis and renal failure are useful predictors, although timing of measurement is important.

Association of decreased serum protein fractions with Clostridium difficile infection in the acute care setting: a case–control study

Aim: This study examines the association of decreased levels of serum proteins with the occurrence of Clostridium difficile-associated diarrhea (CDAD) in hospitalized patients. Materials & methods: This is a retrospective case–control study using a case cohort (n = 171) that had been described in an earlier study and a cohort of 332 contemporaneous controls. Results: Patients with CDAD had significantly lower serum levels of albumin, total protein and globulins, and decreased albumin/globulin ratio (p < 0.0001 for all parameters). After adjustment for confounders, hypoproteinemia was more closely associated with CDAD than either hypoalbuminemia or albumin/globulin ratio. Hypoproteinemia exhibited an odds ratios of 10.6 (95% CI: 6.62–17.0) after adjustment for race, and 11.0 (95% CI: 6.88–17.1) after adjustment for age. Conclusion: Decreased total serum protein is more closely associated with CDAD than hypoalbuminemia.

Identifying patients at risk of severe Clostridium difficile-associated disease

Clostridium difficile infection is responsible for a wide spectrum of clinical presentations, ranging from mild diarrhoea to fatal toxic colitis. This article reviews factors which may identify individuals who are at high risk of severe C. difficile-associated disease, and aims to help clinicians predict patients at risk of severe disease.

The appendix may protect against Clostridium difficile recurrence

BACKGROUND & AIMS

Several risk factors have been identified for the development of recurrent Clostridium difficile infection (CDI) that alter host immunity and disrupt colonic flora. Although the function of the appendix has been debated, its active, gut-associated lymphoid tissue and biofilm production indicate potential roles in recovery from initial CDI and protection against recurrent CDI. We investigated whether the presence or absence of an appendix is associated with CDI recurrence.

METHODS

We reviewed the medical records of adult inpatients with CDI who were admitted to a tertiary-care teaching hospital from 2005 to 2007 to identify those with and without an appendix. The primary dependent variable for statistical analysis was CDI recurrence.

RESULTS

In a multivariate analysis of 11 clinical variables, the presence of an appendix was associated inversely with CDI recurrence (P < .0001; adjusted relative risk, .398). Age older than 60 years also was associated with CDI recurrence (P = .0280; adjusted relative risk, 2.44).

CONCLUSIONS

The presence of an appendix has a significant and independent, inverse association with CDI recurrence, but this finding requires validation in a prospective study. Assessing the presence or absence of an appendix might be useful in predicting CDI recurrence.

Clinical approach to severe Clostridium difficile infection: update for the hospital practitioner

The rising incidence of Clostridium difficile (C. difficile) infection or CDI is now a problem of pandemic proportions. The NAP1 hypervirulent strain of C. difficile is responsible for a majority of recent epidemics and the widespread use of fluoroquinolone antibiotics may have facilitated the selective proliferation of this strain. The NAP1 strain also is more likely to cause severe and fulminant colitis characterized by marked leukocytosis, renal failure, hemodynamic instability, and toxic megacolon. No single test suffices to diagnose severe CDI, instead; the clinician must rely on a combination of clinical acumen, laboratory testing, and radiologic and endoscopic modalities. Although oral vancomycin and metronidazole are considered standard therapies in the medical management of CDI, recently it has been demonstrated that vancomycin is the more effective antibiotic in cases of severe disease. Moreover, early surgical consultation is necessary in patients who do not respond to medical therapy or who demonstrate rising white blood cell counts or hemodynamic instability indicative of fulminant colitis. Subtotal colectomy with end ileostomy is the procedure of choice for fulminant colitis. When applied to select patients in a judicious and timely fashion, surgery can be a life-saving intervention. In addition to these therapeutic approaches, several investigational treatments including novel antibiotics, fecal bacteriotherapy and immunotherapy have shown promise in the care of patients with severe CDI.

CSI: a severity index for Clostridium difficile infection at the time of admission

Clostridium difficile is a common cause of nosocomial diarrhoea in the USA. To develop a score model that would help to identify severe versus mild or moderate C. difficile infection (CDI) upon admission we performed a retrospective cohort study. Between January 2004 and December 2007, 255 patients met inclusion criteria for this study. Severe CDI was defined as cases that required colectomy, intensive care unit management, ended in death, or hospitalisation of >10 days. Data recorded included past medical history, physical examination on admission, laboratory data and imaging/colonoscopy data. To create the CDI severity index (CSI) score, we included four risk factors for severe CDI that were identified by univariate analysis: history of malignancy, white blood cell count at admission >20,000/dL, blood albumin <3.0mg/dL, and creatinine at admission >1.5-fold the baseline value. One point was assigned to each of the risk factors. As indicated by a c-statistic of 0.78, the CSI score predicted severe CDI much better than chance (c-statistics of 0.50). The risk of developing severe CDI increased by a factor of 2.9 (95% CI: 1.82-4.59) for each 1-point increase in the CSI score. A CSI score with a cut-off value of 2 had a sensitivity and specificity of 82% and 65%, respectively. The CSI score may quantify the risk of severe CDI at the time of admission, and help in early identification of patients who may benefit from more aggressive treatment.

Systematic review: Clostridium difficile and inflammatory bowel disease

BACKGROUND

There is increasing concern about the apparently rising incidence and worsening outcome of Clostridium difficile infection (CDI) associated with inflammatory bowel disease (IBD). We have systematically reviewed the literature to evaluate the incidence, risk factors, endoscopic features, treatment and outcome of CDI complicating IBD.

AIM

To systematically review: clostridium difficile & inflammatory bowel disease.

METHODS

Structured searches of Pubmed up to September 2010 for original, cross-sectional, cohort and case-controlled studies were undertaken.

RESULTS

Of 407 studies, 42 met the inclusion criteria: their heterogeneity precluded formal meta-analysis. CDI is commoner in active IBD, particularly ulcerative colitis, than in controls. Certainty about a temporal trend to its increasing incidence in IBD is compromised by possible detection bias and miscoding. Risk factors include immunosuppressants and antibiotics, the latter less commonly than in controls. Endoscopy rarely shows pseudomembranes and is unhelpful for diagnosing CDI in IBD. There are no controlled therapeutic trials of CDI in IBD. In large studies, outcome of CDI in hospitalised IBD patients appears worse than in controls.

CONCLUSIONS

The complication of IBD by Clostridium difficile infection has received increasing attention in the past decade, but whether its incidence is really increasing or its outcome worsening remains unproven. Therapeutic trials of Clostridium difficile infection in IBD are lacking and are needed urgently.

Clostridium difficile infection in Europe: a hospital-based survey

BACKGROUND

Little is known about the extent of Clostridium difficile infection in Europe. Our aim was to obtain a more complete overview of C difficile infection in Europe and build capacity for diagnosis and surveillance.

METHODS

We set up a network of 106 laboratories in 34 European countries. In November, 2008, one to six hospitals per country, relative to population size, tested stool samples of patients with suspected C difficile infection or diarrhoea that developed 3 or more days after hospital admission. A case was defined when, subsequently, toxins were identified in stool samples. Detailed clinical data and stool isolates were collected for the first ten cases per hospital. After 3 months, clinical data were followed up.

FINDINGS

The incidence of C difficile infection varied across hospitals (weighted mean 4·1 per 10,000 patient-days per hospital, range 0·0-36·3). Detailed information was obtained for 509 patients. For 389 of these patients, isolates were available for characterisation. 65 different PCR ribotypes were identified, of which 014/020 (61 patients [16%]), 001 (37 [9%]), and 078 (31 [8%]) were the most prevalent. The prevalence of PCR-ribotype 027 was 5%. Most patients had a previously identified risk profile of old age, comorbidity, and recent antibiotic use. At follow up, 101 (22%) of 455 patients had died, and C difficile infection played a part in 40 (40%) of deaths. After adjustment for potential confounders, an age of 65 years or older (adjusted odds ratio 3·26, 95% CI 1·08-9·78; p=0·026), and infection by PCR-ribotypes 018 (6·19, 1·28-29·81; p=0·023) and 056 (13·01; 1·14-148·26; p=0·039) were significantly associated with complicated disease outcome.

INTERPRETATION

PCR ribotypes other than 027 are prevalent in European hospitals. The data emphasise the importance of multicountry surveillance to detect and control C difficile infection in Europe.

FUNDING

European Centre for Disease Prevention and Control.

The growing incidence and severity of Clostridium difficile infection in inpatient and outpatient settings

Clostridium difficile infection (CDI) is a leading cause of nosocomial infections, with disease severity ranging from mild diarrhea to fulminant colitis. The incidence and severity of CDI has been on the rise over the last 10-20 years, with CDI being increasingly described outside healthcare settings and in populations previously thought to be at low risk. There has also been an increase in the morbidity, mortality and economic burden associated with CDI in the last several years. This increasing incidence and severity is thought to be at least partially due to frequent antibiotic use and the emergence of a hypervirulent C. difficile strain.

Clinical predictors and risk factors for relapsing Clostridium difficile infection

BACKGROUND

Clostridium difficile infection (CDI) is a common cause of morbidity among hospitalized patients. Multiple factors have been associated with primary CDI, but risk factors for CDI relapses are less well described.

METHODS

This was a retrospective cohort study of patients with CDI over a 15-month period. We compared patients with relapsing and nonrelapsing CDI, including risk factors associated with primary CDI and other variables hypothesized to be associated with relapsing CDI and 90-day mortality. Multivariable logistic regression models were created to examine risk factors for relapse and 90-day mortality.

RESULTS

One hundred twenty-nine consecutive patients with CDI were included; 38 (29%) had relapsing CDI. Factors associated with relapsing CDI included fluoroquinolone use (71% versus 49%, P = 0.04) and incidence of stroke (29% versus 12%, P = 0.02). In a regression model, use of a fluoroquinolone was associated with relapsing CDI (OR = 2.52, 95% CI = 1.11-5.72). Factors associated with 90-day mortality included higher Charlson comorbidity index score (4.34 +/- 1.71 versus 3.42 +/- 2.08, P = 0.02), severe CDI (58% versus 32%, P = 0.01), and the use of piperacillin/tazobactam (45% versus 23%, P = 0.03) or meropenem (10% versus 1%, P = 0.04). In the regression analysis, 90-day mortality was associated with severe CDI (OR = 1.76; 95% CI = 1.19-2.59).

CONCLUSION

Fluoroquinolone use and prior stroke are associated with an increased risk of relapsing CDI. Relapsing CDI and severe CDI are both associated with increased 90-day mortality.

European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance document for Clostridium difficile infection (CDI)

Clostridium difficile infection (CDI) is a potentially fatal illness with an increasing incidence worldwide. Despite extensive ongoing research into CDI treatment, management of CDI still poses important problems, such as a high propensity to relapse and refractoriness to treatment, especially when there is an ileus and oral drugs cannot be administered. This guideline evaluates the available literature, discusses criteria for disease severity and provides recommendations for CDI treatment, indicating level of evidence and strength of recommendation.

Intravenous immunoglobulin for the treatment of severe Clostridium difficile colitis: an observational study and review of the literature

BACKGROUND

Clostridium difficile colitis (CDC) is the most common cause of hospital-acquired diarrhea. The increase in the incidence and fatality rate of CDC over the past decade has stimulated a search for new therapies, including intravenous immunoglobulin (IVIG). We report our experience with IVIG for the treatment of 21 patients with severe CDC.

METHOD

Retrospective review of patients with severe CDC who received IVIG between July 2002 and April 2006 at a teaching hospital. The existing literature on IVIG infusion for severe CDC was also reviewed.

RESULTS

Twenty-one of 1230 patients with CDC were treated with IVIG. The mean age was 68 (range, 35-98) years, with mean hospital stay of 23 (range, 9-64) days. Conventional treatment was used for an average of 8 (range, 1-25) days before IVIG infusion. All patients had evidence of pancolitis (radiologically) or ileus (clinically). The mean Acute Physiological Assessment and Chronic Health Evaluation (APACHE II) score was 25 (range, 6-39) at day 1 of IVIG infusion. Nine patients (43%) survived their hospitalization with colitis resolution while 12 (57%) died. One patient developed pulmonary edema after IVIG infusion. Symptoms resolved after an average of 10 (range, 2-20) days for survivors. Two patients underwent urgent colectomy.

CONCLUSIONS

This is the largest case series describing IVIG use for patients with severe CDC and the one with the highest mortality rate to date. The use of IVIG in this setting does not seem to benefit all patients. Benefit appears to depend on the extent of systemic involvement. Further studies are needed before adopting IVIG as routine treatment for severe CDC.

Clinical risk factors for severe Clostridium difficile-associated disease

Identifying patients who are at high risk for severe Clostridium difficile-associated disease (CDAD) early in the course of their infection may help clinicians improve outcomes. Therefore, we compared clinical features associated with severe versus nonsevere CDAD by retrospectively reviewing records of hospitalized patients whose fecal assays were positive for C. difficile toxin. Of 336 patients, 12.2% had severe disease and 10.1% died from all causes. Regression modeling showed the following to be significantly associated with severe CDAD (p< or =0.05): age >70 years (odds ratio [OR] 3.35), maximum leukocyte count >20,000 cells/mL (OR 2.77), minimum albumin level <2.5 g/dL (OR 3.44), maximum creatinine level >2 mg/dL (OR 2.47), small bowel obstruction or ileus (OR 3.06), and computed tomography scan showing colorectal inflammation (OR 13.54). These clinical and laboratory markers for severe disease may be useful for identifying patients at risk for serious outcomes or death.

Clostridium difficile-associated enteric disease after percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has become established as a useful enteral nutrition technique. Although various adverse events related to PEG are known, few reports have described Clostridium difficile-associated enteric disease (CDED) after PEG. We encountered several cases of CDED with onset soon after PEG. The present study examined these cases in detail and analyzed potential risk factors.

METHODS

A total of 239 patients underwent PEG at our hospital from 1999, and the subjects comprised 233 patients for whom data could be statistically analyzed. CDED with onset soon after PEG was defined for cases with symptoms within 1 month after PEG. We investigated features and prognosis of these cases. A total of 19 predictors were chosen, and logistic regression analysis was performed using CDED with onset soon after PEG as a dependent variable.

RESULTS

Mean patient age was high, and about 65% were men. Their body weights were low and their general condition was markedly poor. CDED with onset soon after PEG was shown in 15 patients (6.4%). Although oral administration of vancomycin resulted in prompt recovery in most cases, enteral nutrition was interrupted for a long period, and the general condition deteriorated markedly in two patients. Logistic regression analysis identified "past history of CDED" and "antibiotic dosing period at PEG" as risk factors for CDED onset soon after PEG.

CONCLUSIONS

CDED occurred with onset soon after PEG at a comparatively high rate. Our analysis suggested "past history of CDED" and "antibiotic dosing period at PEG" as risk factors for CDED after PEG.

Predictors of serious complications due to Clostridium difficile infection

BACKGROUND

Identifying individuals with severe Clostridium difficile infection (CDI) at risk for major complications has become an important objective. Presence of clinical variables that predict complications from CDI would have the potential to strongly influence management.

AIM

To determine which clinical variables predict complications from CDI.

METHODS

Cross-sectional study of all individuals admitted to Temple University Hospital between 12/1/03 and 7/1/08 with the primary discharge diagnosis of CDI were eligible. Only patients experiencing their first episode of CDI were included. Abstracted data included demographic, physiological, laboratory, radiological, endoscopic, pharmacy and outcome data. Response was categorized as none, partial or complete. Complications attributed to CDI were defined as colon resection or death.

RESULTS

Overall 32 of 200 patients (16%) experienced a complication due to CDI including death (n = 20) and colectomy (n = 12). White blood cell count above 30,000 cells/mm(3) (OR = 4.06; 95% CI, 1.28-12.87) and a rise in the creatinine to over 50% above baseline (OR = 7.13; 95% CI, 3.05-16.68) predicted a complication. AROC for percent rise in serum creatinine was 0.73 (95% CI: 0.64-0.85) and 0.62 (95% CI: 0.58-0.80) for white blood cell count.

CONCLUSIONS

Severe white blood cell count elevation and a rise in the creatinine to over 50% above baseline are important independent predictors of serious adverse events due to CDI. These patients likely would benefit from more intensive care and early surgical consultation.