1
|
Terzaki M, Kouroupis D, Zarras C, Molyvas D, Michailidou C, Pateinakis P, Mpani K, Soukiouroglou P, Paida E, Simoulidou E, Chatzimichailidou S, Petidis K, Pyrpasopoulou A. The Incidence of Clostridioides difficile Infection in the Post-COVID-19 Era in a Hospital in Northern Greece. Diseases 2024; 12:190. [PMID: 39195189 DOI: 10.3390/diseases12080190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/15/2024] [Accepted: 08/19/2024] [Indexed: 08/29/2024] Open
Abstract
Clostridioides difficile infection (CDI) has evolved to be the most significant cause of healthcare-associated diarrhoea and one of the leading representatives of healthcare-associated infections, with a high associated mortality. The aim of this retrospective study was to record the incidence rates and the epidemiological and clinical features of CDI in a large tertiary hospital of northern Greece in the years 2022-2023. All patients with CDI-compatible symptomatology and a positive CDI diagnostic test (GDH-glutamate dehydrogenase and toxin-positive FIA-Fluorescent Immuno-chromatography-SD Biosensor, and/or film array) were included (104 from a total of 4560 admitted patients). Their demographic, laboratory, and clinical data were recorded and analysed. The incidence of CDI in admitted patients was found to be higher than previous reports in the geographical area, reaching 54.6/10,000 patient days and following a rising trend over the course of the study. Thirty-day mortality was high (39.4%), potentially related to new emerging hypervirulent C. difficile strains. In view of the high prevalence of multidrug-resistant organisms in the region, and the significant mortality associated with this infection, these findings particularly point to the need for the implementation of organized surveillance and infection prevention protocols.
Collapse
Affiliation(s)
- Maria Terzaki
- 2nd Propedeutic Department of Internal Medicine, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Dimitrios Kouroupis
- 2nd Propedeutic Department of Internal Medicine, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Charalampos Zarras
- Microbiology Laboratory, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Dimitrios Molyvas
- 2nd Propedeutic Department of Internal Medicine, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Chrysi Michailidou
- Microbiology Laboratory, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Panagiotis Pateinakis
- 2nd Propedeutic Department of Internal Medicine, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Konstantina Mpani
- Microbiology Laboratory, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Prodromos Soukiouroglou
- Microbiology Laboratory, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Eleftheria Paida
- 2nd Propedeutic Department of Internal Medicine, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Elisavet Simoulidou
- 2nd Propedeutic Department of Internal Medicine, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Sofia Chatzimichailidou
- 2nd Propedeutic Department of Internal Medicine, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Konstantinos Petidis
- 2nd Propedeutic Department of Internal Medicine, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| | - Athina Pyrpasopoulou
- 2nd Propedeutic Department of Internal Medicine, Hippokration General Hospital Thessaloniki, 54642 Thessaloniki, Greece
| |
Collapse
|
2
|
Tsankof A, Protopapas AA, Mantzana P, Protonotariou E, Skoura L, Protopapas AN, Savopoulos C, Mimidis K. Clostridioides difficile infection in patients with and without COVID-19 during the pandemic: A retrospective cohort study from a tertiary referral hospital. Anaerobe 2024; 88:102864. [PMID: 38754772 DOI: 10.1016/j.anaerobe.2024.102864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES This study aims to detect the prevalence and specific characteristics of Clostridioides difficile infection (CDI) during the COVID-19 pandemic. METHODS In this retrospective observational study, conducted in a tertiary hospital in Greece between May 2021 and October 2022, patients with CDI from COVID-19 and Internal Medicine wards were enrolled and compared based on epidemiological and disease-associated data. RESULTS In total, 4322 patients were admitted, and 435 samples for CDI were analyzed, with 104/435 (23.9 %) sample positivity and 2.4 % prevalence. We observed an increased prevalence of CDI compared to the beginning of the COVID-19 pandemic (prevalence = 1.7 %, p = 0.003). 35.6 % of the CDI patients were hospitalized in the COVID-19 ward and 64.4 % in the Internal Medicine ward. COVID-19 patients were younger (p = 0.02) with a lower Charlson Comorbidity Index (CCI) compared to the Internal Medicine ward patients (p < 0.001). With regards to the origin of CDI cases, in the Internal Medicine ward, 68.7 % presented with Hospital-Onset CDI, 17.9 % with Community Onset-Healthcare Associated CDI and 13.4 % with Community Associated CDI, while in the COVID-19 ward, the respective percentages were 86.5 %, 5.4 % and 8.1 %. Finally, there was an increased CDI-related CFR (Case Fatality Ratio) in the Internal Medicine ward compared to the COVID-19 ward (28.4 % vs. 5.4 %, p = 0.001). CONCLUSIONS Increased CDI prevalence and testing were observed compared to the beginning of the COVID-19 pandemic. Lower CDI-related CFR was observed in patients with COVID-19, which may be credited to the patients' significantly lower median age and CCI, as well as to the majority of deaths being due to respiratory failure.
Collapse
Affiliation(s)
- Alexandra Tsankof
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece
| | - Adonis A Protopapas
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece.
| | - Paraskevi Mantzana
- Department of Microbiology, Aristotle University οf Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece
| | - Efthymia Protonotariou
- Department of Microbiology, Aristotle University οf Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece
| | - Lemonia Skoura
- Department of Microbiology, Aristotle University οf Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece
| | - Andreas N Protopapas
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece
| | - Christos Savopoulos
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece
| | - Konstantinos Mimidis
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, 68100, Alexandroupoli, Greece
| |
Collapse
|
3
|
Kachrimanidou M, Metallidis S, Tsachouridou O, Harmanus C, Lola V, Protonotariou E, Skoura L, Kuijper E. Predominance of Clostridioides difficile PCR ribotype 181 in northern Greece, 2016-2019. Anaerobe 2022; 76:102601. [PMID: 35688364 DOI: 10.1016/j.anaerobe.2022.102601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 05/22/2022] [Accepted: 06/03/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The epidemiology of Clostridioides difficile infection (CDI) has undergone many changes since the beginning of this century and continues to evolve based on recent studies. Here, we performed a molecular analysis of C. difficile isolates in northern Greece across 10 health-care facilities, spanning from 2016 to 2019. METHODS 221 C. difficile isolates were cultured from stool samples of hospitalized patients with diarrhea and screened by PCR for the presence of the toxin A (tcdA), toxin B (tcdB), the binary toxin (cdtA and cdtB) genes and the regulating gene of tcdC. PCR ribotyping of the cultured isolates was performed by a standardized protocol for capillary gel-based PCR ribotyping and an international database with well-documented reference strains. RESULTS Thirty-five different PCR ribotypes were identified. The most common RTs identified were: 181 (36%, 80/221), 017 (10%, 21/221), 126 (9%, 19/221), 078 (4%, 9/221) and 012 (4%, 8/221). Notably, the predominant RT181, with toxin profile tcdA+tcdB+cdtA+cdtB+, was identified in seven out of ten participating hospitals. CONCLUSIONS Multiple C. difficile ribotypes have been circulating in the northern Greece region with RTs 181 (closely related to 027), 017, 126 and 078 being predominant.
Collapse
Affiliation(s)
- Melina Kachrimanidou
- First Department of Microbiology, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece.
| | - Symeon Metallidis
- First Internal Medicine Department, Infectious Diseases Division, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Greece
| | - Olga Tsachouridou
- First Internal Medicine Department, Infectious Diseases Division, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Greece
| | - Celine Harmanus
- Department of Medical Microbiology, Center of Infectious Diseases, Leiden University Medical Center, Leiden, And National Institute of Public Health, Bilthoven, the Netherlands
| | - Vassiliki Lola
- First Department of Microbiology, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Efthymia Protonotariou
- Department of Microbiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lemonia Skoura
- Department of Microbiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ed Kuijper
- Department of Medical Microbiology, Center of Infectious Diseases, Leiden University Medical Center, Leiden, And National Institute of Public Health, Bilthoven, the Netherlands
| |
Collapse
|
4
|
Viazis N, Pontas C, Karmiris K, Dimas I, Fragaki M, Paspatis G, Drygiannakis I, Koutroubakis IE, Moschovis D, Tzouvala M, Theocharis G, Tsolias C, Thomopoulos K, Zampeli E, Axiaris G, Michopoulos S, Belesiotou E, Banasa M, Maraki S, Kouskoumpekou F, Apostolopoulos G, Stamouli V, Prifti H, Mantzaris GJ. Prevalence of Clostridium difficile infection among hospitalized inflammatory bowel disease patients in Greece. Eur J Gastroenterol Hepatol 2019; 31:773-776. [PMID: 30973416 DOI: 10.1097/meg.0000000000001414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is an independent risk factor for Clostridium difficile infection (CDI), which is associated significantly with disease severity. We aimed to determine the rates of CDI among hospitalized IBD patients in major tertiary referral hospitals in Greece. PATIENTS AND METHODS A retrospective analysis was carried out of stool cultures from hospitalized patients investigated for diarrhea, during 2016, tested for CDI with glutamate dehydrogenase (GDH) and toxins A and B. RESULTS In total, 6932 patients were tested for CDI; 894 were positive for GDH (12.89%) and 339 were also positive for C. difficile toxin (4.89%). The prevalence of CDI among all hospitalized patients was 1.6/1000 patient-days. Among these, there were 401 IBD patients, and 62 were positive for GDH (15.46%) and 30 were also positive for C. difficile toxin (7.48%). The prevalence of CDI in IBD patients was 2.5/1000 patient-days, significantly higher than in non-IBD hospitalized patients (30/401 vs. 309/6531, P=0.013). Among the 30 IBD patients (ulcerative colitis=18, Crohn's disease=12) with CDI, six were receiving biologics, three were on corticosteroids [one combined with azathioprine (AZA) and one combined with 5-ASA], nine were on AZA monotherapy and 12 were on 5-ASA monotherapy. The prevalence of CDI among patients receiving AZA monotherapy was significantly higher than in patients receiving other medications (9/68 vs. 21/333, P=0.047). Mild CDI (n=28) was treated with metronidazole and/or vancomycin, whereas severe CDI (n=2) was treated with vancomycin. CONCLUSION The prevalence of CDI is higher in hospitalized IBD patients than those without IBD and AZA monotherapy increases the risk of CDI.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Maria Banasa
- Microbiology Department, Venizeleio General Hospital
| | - Sofia Maraki
- Microbiology Department, University Hospital Heraklion, Heraklion
| | | | | | | | - Heleni Prifti
- Microbiology Department, Alexandra General Hospital, Athens, Greece
| | | |
Collapse
|
5
|
Matthaiou DK, Delga D, Daganou M, Koutsoukou A, Karabela N, Mandragos KE, Kalogeropoulou E, Dimopoulos G. Characteristics, risk factors and outcomes of Clostridium difficile infections in Greek Intensive Care Units. Intensive Crit Care Nurs 2019; 53:73-78. [PMID: 30979531 DOI: 10.1016/j.iccn.2019.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clostridium difficile is one of the major causes of diarrhoea among critically ill patients and its prevalence increases exponentially in relation to the use of antibiotics and medical devices. We sought to investigate the incidence of C. difficile infection in Greek units, and identify potential risk factors related to C. difficile infection. METHODS A prospective multicenter cohort analysis of critically ill patients (3 ICUs from 1/1/2014 to 31/12/2014). RESULTS Among 970(100%) patients, 95(9.79%) with diarrhoea, were included. Their demographic, comorbidity and clinical characteristics were recorded on admission to the unit. The known predisposing factors for the infection were recorded and the diagnostic tests to confirm C. difficile were conducted, based on the current guidelines. The incidence of C. difficile infection was 1.3% (n = 13). All-cause mortality in patients with diarrhoea, C. difficile infection and attributable mortality in patients with C. difficile infection was 28%, 38.5% and 30.8% respectively. Sequential Organ Failure Assessment (SOFA) scores on admission were significantly lower and prior C. difficile infection was more common in patients with current C. difficile infection. Regarding other potential risk factors, no difference was found between groups. No factor was independently associated with C. difficile infection. CONCLUSIONS C. difficile infection is low in Greek intensive care units, but remains a serious problem among the critically-ill. Mortality was similar to reports from other countries. No factor was independently associated with C. difficile infection.
Collapse
Affiliation(s)
- Dimitrios K Matthaiou
- Department of Critical Care Medicine, "ATTIKON" University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitra Delga
- Department of Critical Care Medicine, "ATTIKON" University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Daganou
- Department of Critical Care, "SOTIRIA" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonia Koutsoukou
- Department of Critical Care, "SOTIRIA" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Niki Karabela
- Department of Critical Care, "Korgialenio Benakio" Red Cross General Hospital, Athens, Greece
| | | | - Eleni Kalogeropoulou
- Department of Microbiology, "ATTIKON" University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Dimopoulos
- Department of Critical Care Medicine, "ATTIKON" University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| |
Collapse
|
6
|
Extended-pulsed fidaxomicin versus vancomycin for Clostridium difficile infection: EXTEND study subgroup analyses. Eur J Clin Microbiol Infect Dis 2019; 38:1187-1194. [PMID: 30911926 PMCID: PMC6520315 DOI: 10.1007/s10096-019-03525-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/28/2019] [Indexed: 02/08/2023]
Abstract
Poor outcomes following Clostridium difficile infection (CDI) have been associated with advanced age, presence of cancer and C. difficile PCR-ribotype 027. The impact of baseline risk factors on clinical outcomes was evaluated using data from the EXTEND study, in which rate of sustained clinical cure (SCC) in the overall population was significantly higher with an extended-pulsed fidaxomicin (EPFX) regimen than with vancomycin. Patients aged ≥ 60 years received EPFX (fidaxomicin 200 mg twice daily, days 1–5; once daily on alternate days, days 7–25) or vancomycin (125 mg four times daily, days 1–10). We analysed outcomes by advanced age, cancer diagnosis, CDI severity, prior CDI occurrence and infection with PCR-ribotype 027. The primary endpoint was SCC 30 days after end of treatment (EOT; clinical response at test-of-cure with no subsequent recurrence). SCC rates 30 days after EOT did not differ significantly between EPFX (124/177, 70.1%) and vancomycin (106/179, 59.2%) regardless of age, cancer diagnosis, CDI severity and prior CDI. In patients with PCR-ribotype 027, SCC rate 30 days after EOT was significantly higher with EPFX (20/25, 80%) than with vancomycin (9/22, 40.9%) (treatment difference, 39.1%; 95% CI, 13.2–64.9; P = 0.006). Subgroup analyses from the EXTEND study suggest that EPFX is efficacious as a potential treatment for CDI regardless of age, cancer diagnosis, infection with PCR-ribotype 027, CDI severity or prior CDI. ClinicalTrials.gov identifier: NCT02254967.
Collapse
|
7
|
Implementation of multimodal infection control and hand hygiene strategies in acute-care hospitals in Greece: A cross-sectional benchmarking survey. Am J Infect Control 2018; 46:1097-1103. [PMID: 29778434 DOI: 10.1016/j.ajic.2018.04.217] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND In this first attempt to suggest achievable standards for improvement in hospital infection prevention and control (IPC) in Greece, we assessed main IPC structure and process indicators emphasizing hand hygiene. METHODS Acute-care hospitals across the country participated in a cross-sectional survey by completing the World Health Organization Hand Hygiene Self-assessment Framework (HHSAF) and by providing hospital-level IPC indicators. RESULTS Seventeen hospitals completed the survey, comprising 14% of the country's public hospitals. Median IPC staffing levels were 0.8 nurses and 0.5 doctors per 250 beds. Few hospitals implemented full multimodal IPC programs. The HHSAF indicated that appropriate hand hygiene practices and promotion strategies were in place in most hospitals, but the mean HHSAF score of 289 was lower compared with studies in Italy (mean, 332; P = .040) and the United States (mean, 373; P < .001). Presence of 1 additional IPC nurse was independently associated with increases of 53% in the HHSAF median score for training-education (P = .035) and by 38% in the lower 30th percentile HHSAF score for safety climate (P = .049). CONCLUSIONS Surveyed hospitals are, on average, at an intermediate level in hand hygiene practice but require improvements on training-education, evaluation-feedback, and safety climate. Ensuring adequate IPC nurse staffing levels and systematically implementing multimodal IPC programs may lead to substantial improvements.
Collapse
|
8
|
Kachrimanidou M, Tsachouridou O, Ziogas IA, Christaki E, Protonotariou E, Metallidis S, Skoura L, Kuijper E. Clostridium difficile infections in a university hospital in Greece are mainly associated with PCR ribotypes 017 and 126. J Med Microbiol 2017; 66:1774-1781. [PMID: 29087273 DOI: 10.1099/jmm.0.000623] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Data regarding the incidence and molecular epidemiology of Clostridium difficile infections (CDIs) in Greece are limited. METHODOLOGY A retrospective study of all laboratory-confirmed CDI cases in a university hospital during a 9-month period. Stool samples from inpatients with diarrhoea were tested with a combined glutamate dehydrogenase (GDH) and toxin enzyme immunoassay (EIA) test, as part of a two-step algorithm for CDI testing. All GDH-positive samples were cultured and isolates were further tested for the presence of toxin genes and characterized by PCR ribotyping. RESULTS The incidence of CDI in our hospital was 25 per 10 000 hospital admissions. Of 33 CDI cases, 72.7 % were hospital-acquired. Fourteen different PCR ribotypes were identified, of which 017 (21.2 %), 078/126 (15.1 %) and RT202 and RT106 (9 %) were the most prevalent. Most patients had a risk profile of recent antibiotic use, older age and comorbidities. Despite mild CDI clinical characteristics, six cases showed complications and led to 18.2 % mortality. CONCLUSION The CDI incidence was comparable to that in other European countries. The hypervirulent PCR ribotype 027 was not found, whereas ribotypes 017 and 126 predominated. Most CDI cases were in patients who used antibiotics, emphasizing that antimicrobial stewardship should be considered as a cornerstone for the prevention of CDI.
Collapse
Affiliation(s)
- Melina Kachrimanidou
- First Department of Microbiology, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Olga Tsachouridou
- First Internal Medicine Department, Infectious Diseases Division, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis A Ziogas
- First Internal Medicine Department, Infectious Diseases Division, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eirini Christaki
- First Internal Medicine Department, Infectious Diseases Division, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Protonotariou
- Department of Microbiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Symeon Metallidis
- First Internal Medicine Department, Infectious Diseases Division, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lemonia Skoura
- Department of Microbiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ed Kuijper
- Department of Medical Microbiology, Center of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|