Risk factors for and estimated incidence of community-associated Clostridium difficile infection, North Carolina, USA

Incidence of Clostridioides difficile Infections in Republic of Korea: A Prospective Study With Active Surveillance vs. National Data From Health Insurance Review & Assessment Service

BACKGROUND

Since the emergence of hypervirulent strains of Clostridioides difficile, the incidence of C. difficile infections (CDI) has increased significantly.

METHODS

To assess the incidence of CDI in Korea, we conducted a prospective multicentre observational study from October 2020 to October 2021. Additionally, we calculated the incidence of CDI from mass data obtained from the Health Insurance Review and Assessment Service (HIRA) from 2008 to 2020.

RESULTS

In the prospective study with active surveillance, 30,212 patients had diarrhoea and 907 patients were diagnosed with CDI over 1,288,571 patient-days and 193,264 admissions in 18 participating hospitals during 3 months of study period; the CDI per 10,000 patient-days was 7.04 and the CDI per 1,000 admission was 4.69. The incidence of CDI was higher in general hospitals than in tertiary hospitals: 6.38 per 10,000 patient-days (range: 3.25-12.05) and 4.18 per 1,000 admissions (range: 1.92-8.59) in 11 tertiary hospitals, vs. 9.45 per 10,000 patient-days (range: 5.68-13.90) and 6.73 per 1,000 admissions (range: 3.18-15.85) in seven general hospitals. With regard to HIRA data, the incidence of CDI in all hospitals has been increasing over the 13-year-period: from 0.3 to 1.8 per 10,000 patient-days, 0.3 to 1.6 per 1,000 admissions, and 6.9 to 56.9 per 100,000 population, respectively.

CONCLUSION

The incidence of CDI in Korea has been gradually increasing, and its recent value is as high as that in the United State and Europe. CDI is underestimated, particularly in general hospitals in Korea.

Economic Burden of Clostridioides difficile Infection in European Countries

Clostridioides difficile infection (CDI) remains a considerable challenge to healthcare systems worldwide. Although CDI represents a significant burden on healthcare systems in Europe, few studies have attempted to estimate the consumption of resources associated with CDI in Europe. The reported extra costs attributable to CDI vary widely according to the definitions, design, and methodologies used, making comparisons difficult to perform. In this chapter, the economic burden of healthcare facility-associated CDI in Europe will be assessed, as will other less explored areas such as the economic burden of recurrent CDI, community-acquired CDI, pediatric CDI, and CDI in outbreaks.

Biogeographic distribution and molecular epidemiology of Clostridioides (Clostridium) difficile in Western Australian soils

Clostridioides (Clostridium) difficile is a leading cause of infectious diarrhea in humans and production animals and can be found in a variety of environmental sources. The prevalence and diversity of multi-locus sequence type clade 5 strains of C. difficile in Australian production animals suggest Australia might be the ancestral home of this lineage of One Health importance. To better understand the role of the environment in the colonization of humans and animals in Australia, it is important to investigate these endemic sources. This study describes the prevalence, molecular epidemiology, and biogeographic distribution of C. difficile in soils of Western Australia. A total of 321 soil samples from remote geographical locations across the eight health regions of Western Australia were screened for C. difficile and isolates characterized by PCR ribotyping and toxin gene profiling. C. difficile was isolated from 31.15% of samples, with the highest prevalence in the Perth Metropolitan Health Region (49.25%, n = 33/67). Overall, 52 different strains [PCR ribotypes (RTs)] were identified, with 14 being novel, and 38% (38/100) of isolates being toxigenic, the most common of which was RT014/020. Five unique novel isolates showed characteristics similar to C. difficile clade 5. This is the first study of C. difficile isolated from soils in Australia. The high prevalence and heterogeneity of C. difficile strains recovered suggest that soils play a role in the survival and environmental dissemination of this organism, and potentially its transmission among native wildlife and production animals, and in community and hospital settings.IMPORTANCEClostridium difficile is a pathogen of One Health importance. To better understand the role of the environment in human and animal colonization/infection, it is critical that autochthonous reservoirs/sources of C. difficile be investigated. This is the first study of C. difficile isolated from soils of Western Australia (WA). Here, the ecology of C. difficile in WA is described by examining the geographic distribution, molecular epidemiology, and diversity of C. difficile isolated from soils across WA.

Community-onset Clostridioides difficile infection in south Serbia

BACKGROUND

Data from the past decade indicates that Clostridioides difficile infection (CDI) is not only a nosocomial infection but is also increasingly recognized as a disease in the community.

OBJECTIVE

We aimed to study community-onset (CO) CDI in the various age groups in south Serbia with its clinical characteristics, risk factors and microbiological characterization.

METHODS

The study group included 93 patients with CO-CDI (median age 62). The control group consisted of 186 patients with community-onset diarrhea and stool samples negative tested for CDI.

RESULTS

Of all CDI cases diagnosed with a community onset, 74.19% had a previous contact with a healthcare facility in the previous 12 weeks, but 34.40% have no record on hospitalization in the previous 12 months. Using a multivariate statistical regression model, the following risk factors for CO-CDI development were found; antacid usage (OR = 0.267, 95%C.I.:0.10-0.291, p < 0.01), chronic kidney disease (OR = 0.234, 95%C.I.:0.10-0.51, p < 0.01) and antibiotic use during the prior 2 months (OR = 0.061, 95%C.I.:0.02-0.17, p < 0.01), especially tetracycline's (OR = 0.146, 95% C.I.:0.07-0.22, p < 0.01) and cephalosporin's (OR = 0.110, 95%C.I.:0.14-0.42, p < 0.01). The most common ribotypes (RTs) detected in patients with CO-CDI were RT001 (32.3%) and RT027 (24.7%). All tested toxin producing C. difficile isolates were sensitive to metronidazole, vancomycin and tigecycline. A high rate of resistance to moxifloxacin (73.11%) and rifampicin (23.65%) was found.

CONCLUSION

Patients with CO-CDI had frequently contact with healthcare facility in the previous 12 weeks. Restriction of antacid usage and of high-risk antibiotics in the community may help reduce the incidence of CO-CDI.

Clostridioides difficile infection after appendectomy: An analysis of short-term outcomes from the NSQIP database

BACKGROUND

Clostridioides difficile infection can be a significant complication in surgical patients. The purpose of this study was to describe the incidence and impact on outcomes of Clostridioides difficile infection in adult patients after appendectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program data set was used to identify all patients with the primary procedure code of appendectomy between 2016 and 2018. Patient demographics and clinical characteristics were extracted from the database, and descriptive statistics were performed. A multivariate logistic regression was created to identify predictors of Clostridioides difficile infection following appendectomy.

RESULTS

A total of 135,272 patients who underwent appendectomy were identified, and of those, 469(0.35%) developed Clostridioides difficile infection. Patients with Clostridioides difficile infection were more likely to be older (51.23 vs 40.47 years; P < .0001), female (P = .004), American Society of Anesthesiology score >2 (P < .0001), present with septic shock (P < .0001), or lack functional independence (P < .0001). Patients with Clostridioides difficile infection were more likely to have increased operative time (62.9 vs 50.4 minutes; P < .0001), have perforated appendicitis (48.9% vs 23.5%; P < .0001), and underwent open surgery (7.0% vs 4.0%; P = .0006). Postoperatively, patients with Clostridioides difficile infection required a longer length of stay (4.8 vs 1.8 days; P < .0001), had increased mortality (2.1% vs 0.1%; P < .0001), higher incidences of postoperative abscess (14.9% vs 2.9%; P < .0001), postoperative sepsis (15.1% vs 4.0%; P < .0001), and readmission (30.7% vs 3.4%; all P < .0001). On multivariate analysis, older age (P < .0001), female sex (P = .0043), septic shock (P = .0002), open surgery (P = .037), and dirty wound class (P = .0147) were all independently predictive factors of Clostridioides difficile infection after appendectomy.

CONCLUSION

Clostridioides difficile infection is an uncommon postoperative complication of appendectomy and is associated with worse outcomes and higher mortality. Older patients, female sex, those with sepsis, and those undergoing open surgery are at higher risk for developing Clostridioides difficile infection.

Prevalence, Molecular Characterization and Antimicrobial Susceptibility of Clostridioides difficile Isolated from Pig Carcasses and Pork Products in Central Italy

In the last decade, the incidence and severity of Clostridioides difficile infections (CDIs) in humans have been increasing and community-associated infections have been described. For these reasons, the interest in C. difficile in food and in food animals has increased, suggesting other possible sources of C. difficile acquisition. This study evaluated the presence of C. difficile on pig carcasses at the slaughterhouse and in pork products in Central Italy. The contamination rate on pig carcasses was 4/179 (2.3%). Regarding food samples, a total of 216 pork products were tested (74 raw meat preparations and 142 ready-to-eat food samples made by cured raw meat). The real-time PCR screening was positive for 1/74 raw meat preparation (1.35%) and for 1/142 ready-to-eat food samples (0.7%) C. difficile was isolated only from the raw meat preparation (pork sausage). All the isolated strains were toxigenic and susceptible to all the tested antibiotics. Strains isolated from carcass samples displayed A+B+CDTa+CDTb+ profile, were toxinotype IV and belonged to the same ribotype arbitrary named TV93, while the one isolated from food samples displayed A+B+CDTa-CDTb- profile and it was not possible to determine ribotype and toxinotype, because it was lost after freeze storage. It was concluded that the prevalence of C. difficile in the pork supply chain is very low.

Effective inhibition of Clostridioides difficile by the novel peptide CM-A

Clostridioides difficile infection is the most common cause of nosocomial and antibiotic-associated diarrhea. C. difficile treatment is increasingly likely to fail, and the recurrence rate is high. Antimicrobial peptides are considered an alternative treatment for many infectious diseases, including those caused by antibiotic resistant bacteria. In the present study, we identified a CM peptide, a hybrid of cecropin A and melittin, and its derivative which possesses potent antimicrobial activity against C. difficile strain 630. CM peptide exhibited antibacterial activity with minimum inhibitory concentration of 3.906 μg/ml (2.21 μM). A modified derivative of CM, CM-A, exhibited even greater activity with a minimum inhibitory concentration of 1.953 μg/ml (1.06 μM) and a minimum bactericidal concentration of 7.8125 μg/ml (4.24 μM), which indicates that CM-A peptide is more efficient than its parent peptide. A fluorescence-activated cell sorter analysis revealed that the membrane of C. difficile 630 could be an important target for CM-A. This peptide induced high levels of cell depolarization and cell permeability on C. difficile cell membrane. Moreover, electron microscopy imaging showed that CM-A interferes with the C. difficile cell membrane. Hence, the antimicrobial peptide CM-A may represent a promising novel approach for the treatment of C. difficile infections.

Patients with More Severe IBD Get Clostridioides difficile Rather than Clostridioides difficile Increasing the Severity of IBD

BACKGROUND

Inflammatory bowel disease (IBD) patients who have Clostridioides difficile infection (CDI) have worse outcomes.

AIMS

We aimed to determine whether such outcomes are the result of CDI or whether CDI occurs in patients who have more severe IBD.

METHODS

This was a retrospective study of patients hospitalized for ≥ 2 IBD flares from 2010 to 2019. The primary outcome was time to IBD flare between hospitalizations. First, time to flare was compared between patients who were hospitalized for a flare complicated by CDI and subsequently for a CDI-negative flare (cohort A, denoted +/-) versus patients who were hospitalized for two CDI-negative flares (cohort B, -/-). Second, time between flares was compared within the subset of cohort A patients who had three flares (cohort C, -/+/-) before and after CDI.

RESULTS

Time between flares was a median of 4 months (IQR 1-9) among 51 cohort A patients versus 12 months (IQR 6-38) among 51 cohort B patients (log-rank P < 0.01). In contrast, the median time between flares was similar within cohort C before and after CDI (log-rank P = 0.54). At time of the second IBD flare, patients in cohort A (+/-) were more likely to have moderate or severe disease compared to patients in cohort B (-/-).

CONCLUSIONS

Patients with prior CDI had shorter time to subsequent IBD flare relative to their CDI-negative counterparts. This is not likely due to CDI itself because there was no difference in time between flares before versus after acquiring CDI. Rather, patients who acquire CDI may have more severe IBD.

Proton-Pump Inhibitor Use and the Risk of Community-Associated Clostridium difficile Infection

Background

Proton-pump inhibitors (PPIs) have been reported to increase the risk of community-associated Clostridium difficile infection (CDI), but the association remains disputed.

Methods

A nationwide cohort study among adults in Denmark, 2010–2013, linking register data on C. difficile testing, filled prescriptions, and patient characteristics. All incident episodes of community-associated CDI (ie, positive culture, molecular assay, or toxin test in individuals without previous hospitalization in the prior 12 weeks and without a positive test for C. difficile in the prior 8 weeks) were identified in the Danish National Microbiological Database. Self-controlled case-series analyses were used to estimate incidence rate ratios (IRRs) for community-associated CDI, comparing periods with and without exposure to PPIs. By design, models took fixed confounders such as chronic disease, genetics, and socioeconomic status into account; further, time-varying confounders, including hospital stay and antibiotic and corticosteroid use were adjusted for.

Results

3583 episodes of community-associated CDI were identified, of which 964 occurred during current use of PPIs, 324 occurred 0–6 months after treatment cessation, 123 occurred 6–12 months after treatment cessation, and 2172 occurred during time periods without use of PPIs. The adjusted IRR was 2.03 (95% confidence interval, 1.74–2.36), comparing use of PPI with nonuse. The increased risk remained elevated in later time periods: 1.54 (1.31–1.80) for 0–6 months, 1.24 (1.00–1.53) for 6–12 months after current use.

Conclusions

Use of PPIs was associated with moderately increased risk of community-associated CDI. The risk remained elevated up to 1 year after PPI treatment had ended.

IL-16 and BCA-1 Serum Levels Are Associated with Disease Severity of C. difficile Infection

Clostridioides difficile infection (CDI) is associated with a high risk for complications and death, which requires identifying severe patients and treating them accordingly. We examined the serum level of six cytokines and chemokines (IL-16, IL-21, IL-23, IL-33, BCA-1, TRAIL) and investigated the association between them and patients’ disease severity. Concentrations of six cytokines and chemokines were measured using the MILLIPLEX^®MAP kit (Billerica, MA, USA) in serum samples attained from CDI patients within 24–48 h after laboratory confirmation of C. difficile presence. Demographic and clinical data were collected from medical records. The disease severity score was determined according to guidelines of the “Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America” (SHEA-IDSA). Out of 54 patients, 20 (37%) had mild to moderate disease and 34 (63%) had severe disease. IL-16 (p = 0.005) and BCA-1 (p = 0.012) were associated with a more severe disease. In conclusion, IL-16 and BCA-1, along with other cytokines and chemokines, may serve as biomarkers for the early prediction of CDI severity in the future. An improved and more accessible assessment of CDI severity will contribute to the adjustment of the medical treatment, which will lead to a better patient outcome.

Hospitalized patients with diarrhea: Rate of Clostridioides difficile infection underdiagnosis and drivers of clinical suspicion

OBJECTIVES

Clostridioides difficile infection (CDI) represents a challenging issue, with an evolving epidemiology. Main objectives of our study were: to assess the frequency of diarrhea of overall etiology, including CDI, as a cause of hospital admission or occurring during hospital stay;- to determine the rate of underdiagnosis of community-acquired (CA-), health care associated (HCA)- and hospital onset (HO-) CDI, and explore factors associated with its clinical suspicion by physicians.

METHODS

A prospective cohort study included all hospitalized patients with diarrhea at two acute-care hospitals. C. difficile (CD) tests were performed on every stool samples, irrespective of the treating physician request. Factors associated with the likelihood of CD test request by physicians were assessed.

RESULTS

We enrolled 871 (6%) patients with diarrhea. CD test performed on all diarrheic stool samples was positive in 228 cases (26%); 37, 106, 85 cases of CA- (14%), HCA- (42%) and HO- diarrhea (24%), respectively. Treating physicians did not request CD test in 207 (24%) diarrhea cases. The rate of CDI underdiagnosis was 11% (24/228); it was higher in CA-CDI (27%, 10/37). Logistic regression analysis identified age >65 years (RR 1.1; 95 CI 1.06-1.2) and hospitalizations in the previous 3 months (RR 1.2; 95% CI 1.1-1.3) as independent factors associated with the likelihood of requesting the CD test by the physician. These risk factors differed by epidemiological classification of diarrhea and by hospital.

CONCLUSIONS

Our study confirmed the relevance of CDI underdiagnosis and provided new insights in the factors underlying the lack of CDI clinical suspicion.

A contemporary review of Clostridioides difficile infections in patients with haematologic diseases

Clostridioides (Clostridium) difficile (C. difficile) infection is one of the most common causes of increased morbidity and mortality. Approximately 500 000 C. difficile infections (CDIs) occur each year in the United States, and they result in more than 29 000 deaths. Patients with haematologic diseases are at a higher risk for this infection due to frequent hospitalization and exposure to treatment-associated risk factors. Whilst several currently available antimicrobial agents offer resolution, recurrence of infection remains a major concern. Recent advancement in deciphering C. difficile virulence mechanisms and identification of its allies in contributing to the infection has led to the development of alternative treatment strategies. Here, we will provide a contemporary discussion of how major risk factors in haematologic diseases, such as immunosuppression, chemoradiation, use of antibiotic, proton pump inhibitor and opioid, and deficiency in butyrate and antimicrobial peptides contribute to C. difficile infection. Next, we will highlight different approaches to control and mitigate this infection such as antibiotic stewardship and faecal microbiota transplantation. Finally, we will explore several emerging treatments such as use of pre- and probiotics, immunotherapy and microbiome-sparing agents.

Clostridioides difficile infection and antibiotic prescription rates in the community: Explaining the gender gap

In this cross-sectional population-based study, women had significantly higher crude incidence rates of both community-associated Clostridioides difficile infection (CA-CDI) and ambulatory antibiotic prescriptions compared to men in South Carolina in 2015. After adjustments for antibiotic prescription rates, there was no difference in the incidence rates of CA-CDI between the genders.

Degree of concordance of Clostridioides difficile strains in adults with community-associated C. difficile infection and infants with C. difficile colonization

BACKGROUND

Infants asymptomatically excrete Clostridioides difficile during their first year of life, suggesting that they may represent a source of infection for adults who acquire community-associated C. difficile infection (CA-CDI). The genetic relationship of C. difficile strains from asymptomatic infants and adults with CA-CDI is not well defined.

METHODS

In this study, 50 infants were recruited at birth, and stool samples were collected at routine well-child visits. Adult stool samples collected during the same period and geographical area from patients who were diagnosed with CA-CDI were selected for comparison. C. difficile was cultivated and probed by PCR for toxin genes and were typed by PCR fluorescent ribotyping. Isolates from adults and infants with shared ribotypes were subjected to whole-genome sequencing (WGS).

RESULTS

Of these 50 infants, 36 were positive for C. difficile at least once in their first year of life, with a peak incidence at 6 months. Among 180 infant stool samples, 48 were positive. Of 48 isolates from positive stools, 29 were toxigenic by polymerase chain reaction (PCR) and 8 of 48 stool samples were positive for toxin by enzyme immunoassays (EIAs). Ribotypes F106 and F014-020 were present in both colonized infants and adults with CA-CDI. WGS identified 1 adult-infant pair that differed by 5 single-nucleotide polymorphisms (SNPs). Also, 4 additional adult-infant clusters differed by ≤16 SNPs.

CONCLUSIONS

Infants that are colonized with C. difficile share ribotypes with adults from the same geographical region with CA-CDI. Selected isolates in the 2 populations show a genetic relationship by WGS.

Clostridioides difficile infection in US hospitals: a national inpatient sample study

BACKGROUND

Hypervirulent strains of Clostridioides difficile have altered the landscape of hospital and community outbreaks. We aim to examine and compare spatiotemporal trends, incidence, hospital teaching status, mortality, and cost associated with hospital-acquired Clostridioides difficile infection (HCDI) and community-acquired Clostridioides difficile infection (CCDI).

METHODS

Retrospective cohorts were studied using data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) from 2006 to 2015.

RESULTS

A total of 76,124 cases of HCDI and 190,641 cases of CCDI were identified within the study period. The incidence of HCDI decreased from 8555 in 2006 to 7191 in 2015. Mortality also decreased during the same period (5.9% in 2006 to 1.4% 2015, p < 0.0001). Conversely, CCDI cases increased from 13,823 in 2006 to 20,637 in 2015. CCDI mortality decreased during the same period (4.3% in 2006 to 1.9% 2015, p < 0.0001). Rural hospital centers experienced the sharpest decline in HCDI mortality compared to urban and urban teaching centers (3.8%, p < 0.0001 vs 2.8%, p < 0.0001 vs 2.1%, p < 0.0001). Multivariate logistic regression indicated that increasing age (p = 0.0001), increasing hospital length of stay (p = 0.0001), and Medicare insurance (p = 0.002) were significant predictors of mortality for CDI mortality. Geospatial mapping of CCDI and HCDI revealed that the Eastern and Southern US experienced the largest incidence of CDI over 10 years.

CONCLUSION

The incidence of HCDI has decreased in the past decade while the incidence of CCDI hospitalization is sharply on the rise. While hospital length of stay and mortality has decreased over time, the cost of treating CDI remains high.

Differences in time-to-testing and time-to-isolation between community-onset and hospital-onset Clostridioides difficile cases at a tertiary care VA medical center

BACKGROUND

Delayed identification and isolation of patients with Clostridiodies difficile infection (CDI) may contribute to in-hospital transmission and delay appropriate therapy. To assess potential points for intervention, we conducted a retrospective cohort study to determine differences in time-to-testing and time-to-isolation among community-onset (CO), community-onset healthcare facility-associated (CO-HCFA), and hospital-onset (HO) CDI.

METHODS

We compared clinical and demographic data of all CO, CO-HCFA, and HO CDI patients at our institution between October 2011 and September 2015. We then performed bivariable analysis on our cohorts to identify differences in time-to-testing and time-to-isolation for CO versus CO-HCFA versus HO CDI patients.

RESULTS

355 patients with CDI were hospitalized during the study; 138 (38.9%) with CO CDI, 52 (14.6%) with CO-HCFA CDI, and 165 (46.5%) with HO CDI. 117 (84.8%) CO CDI patients were tested within 1 day of diarrhea onset compared to 41 (78.8%) of CO-HCFA and 113 (68.5%) of HO CDI patients (P < .01). 51 CO CDI patients (36.7%) were placed on empirical isolation precautions at the time of diarrhea onset compared to 22 (43.1%) of CO-HCFA CDI patients and 32 (19.4%) of HO CDI patients (P < .01).

CONCLUSIONS

CO CDI patients are more likely to be isolated empirically and tested earlier than HO CDI patients. Further attention should be paid to isolating hospitalized patients who develop diarrhea as an inpatient.

Clinical characteristics and prognostic factors of extraintestinal infection caused by Clostridioides difficile: analysis of 60 consecutive cases

Data regarding extraintestinal Clostridioides difficile infections (ECDIs) remain scarce and anecdotal. We conducted a retrospective cohort study to investigate characteristics and prognostic factors in patients with ECDI. From January 1997 through December 2018, 60 patients were enrolled and divided into three groups as follows: group A (gastrointestinal [GI] disruption caused by malignancy, n = 13); group B (GI disruption from causes other than malignancy, n = 25); group C (no GI disruption, n = 22). GI disruption was defined as compromised integrity of the GI tract caused by abdominal surgery, perforation, malignancy, enterocolitis, or bleeding. The incidence of ECDI was 2.53 per 100,000 admissions. The most common specimens yielded C. difficile were blood (36.7%), peritoneal fluid (20.0%), and abscesses (16.7%). Six patients (10.0%) had confirmed C. difficile enterocolitis, and 36 patients (60.0%) had a polymicrobial infection. C. difficile bacteremia was significantly more common in group A patients than those in groups B or C (53.8% vs. 48.0% vs. 13.6%, p = 0.02), as was the 30-day mortality rate (69.2% vs. 12.0% vs. 18.2%, respectively; p < 0.001). In multivariate analysis, group A (adjusted odds ratio [aOR], 17.32; 95% confidence interval [CI], 2.96-101.21; p = 0.002) and an age of > 65 years (aOR, 7.09; 95% CI, 1.31-38.45; p = 0.02) were independent risk factors for 30-day mortality. ECDI was uncommonly associated with C. difficile enterocolitis. Two factors, GI disruption caused by malignancy, and old age, were associated with significantly poorer short-term outcomes.

Modeling inpatient and outpatient antibiotic stewardship interventions to reduce the burden of Clostridioides difficile infection in a regional healthcare network

Antibiotic exposure can lead to unintended outcomes, including drug-drug interactions, adverse drug events, and healthcare-associated infections like Clostridioides difficile infection (CDI). Improving antibiotic use is critical to reduce an individual's CDI risk. Antibiotic stewardship initiatives can reduce inappropriate antibiotic prescribing (e.g., unnecessary antibiotic prescribing, inappropriate antibiotic selection), impacting both hospital (healthcare)-onset (HO)-CDI and community-associated (CA)-CDI. Previous computational and mathematical modeling studies have demonstrated a reduction in CDI incidence associated with antibiotic stewardship initiatives in hospital settings. Although the impact of antibiotic stewardship initiatives in long-term care facilities (LTCFs), including nursing homes, and in outpatient settings have been documented, the effects of specific interventions on CDI incidence are not well understood. We examined the relative effectiveness of antibiotic stewardship interventions on CDI incidence using a geospatially explicit agent-based model of a regional healthcare network in North Carolina. We simulated reductions in unnecessary antibiotic prescribing and inappropriate antibiotic selection with intervention scenarios at individual and network healthcare facilities, including short-term acute care hospitals (STACHs), nursing homes, and outpatient locations. Modeled antibiotic prescription rates were calculated using patient-level data on antibiotic length of therapy for the 10 modeled network STACHs. By simulating a 30% reduction in antibiotics prescribed across all inpatient and outpatient locations, we found the greatest reductions on network CDI incidence among tested scenarios, namely a 17% decrease in HO-CDI incidence and 7% decrease in CA-CDI. Among intervention scenarios of reducing inappropriate antibiotic selection, we found a greater impact on network CDI incidence when modeling this reduction in nursing homes alone compared to the same intervention in STACHs alone. These results support the potential importance of LTCF and outpatient antibiotic stewardship efforts on network CDI burden and add to the evidence that a coordinated approach to antibiotic stewardship across multiple facilities, including inpatient and outpatient settings, within a regional healthcare network could be an effective strategy to reduce network CDI burden.

Epidemiology and Risk Factors for Community Associated Clostridioides difficile in Children

OBJECTIVE

To assess which risk factors are associated with community-associated Clostridioides difficile infection (CDI) in children.

STUDY DESIGN

This case control study was a retrospective review of all children 1-17 years of age with stool specimens sent for C difficile testing from January 1, 2012, to December 31, 2016. Cases and controls were children who had C difficile testing performed in the community or first 48 hours of hospital admission and >12 weeks after hospital discharge, with no prior positive C difficile testing in last 8 weeks, without other identified causes of diarrhea, and with clinical symptoms. Cases had positive confirmatory testing for C difficile. Controls had negative testing for C difficile and were matched to cases 1:1 by age and year of specimen collection.

RESULTS

The overall incidence rate of community-acquired CDI in this cohort was 13.7 per 100 000 children per year. There was a substantial increase in community-acquired CDI from 9.6 per 100 000 children per year in 2012 to a peak of 16.9 per 100 000 children per year in 2015 (Cochran-Armitage test for trend P = .002). The risk factors for community-acquired CDI included non-Hispanic ethnicity; amoxicillin-clavulanate, cephalosporin, and clindamycin use within the previous 12 weeks; a previous positive C difficile test within 6 months; and increased health care visits in the last year.

CONCLUSIONS

As rates of community-acquired CDI are increasing, enhanced antibiotic stewardship and recognition of health care disparities may ease the burden of community-acquired CDI.

Creation of a Geospatially Explicit, Agent-based Model of a Regional Healthcare Network with Application to Clostridioides difficile Infection

Agent-based models (ABMs) describe and simulate complex systems comprising unique agents, or individuals, while accounting for geospatial and temporal variability among dynamic processes. ABMs are increasingly used to study healthcare-associated infections (ie, infections acquired during admission to a healthcare facility), including Clostridioides difficile infection, currently the most common healthcare-associated infection in the United States. The overall burden and transmission dynamics of healthcare-associated infections, including C difficile infection, may be influenced by community sources and movement of people among healthcare facilities and communities. These complex dynamics warrant geospatially explicit ABMs that extend beyond single healthcare facilities to include entire systems (eg, hospitals, nursing homes and extended care facilities, the community). The agents in ABMs can be built on a synthetic population, a model-generated representation of the actual population with associated spatial (eg, home residence), temporal (eg, change in location over time), and nonspatial (eg, sociodemographic features) attributes. We describe our methods to create a geospatially explicit ABM of a major regional healthcare network using a synthetic population as microdata input. We illustrate agent movement in the healthcare network and the community, informed by patient-level medical records, aggregate hospital discharge data, healthcare facility licensing data, and published literature. We apply the ABM output to visualize agent movement in the healthcare network and the community served by the network. We provide an application example of the ABM to C difficile infection using a natural history submodel. We discuss the ABM's potential to detect network areas where disease risk is high; simulate and evaluate interventions to protect public health; adapt to other geographic locations and healthcare-associated infections, including emerging pathogens; and meaningfully translate results to public health practitioners, healthcare providers, and policymakers.

Significance of Clostridium difficile in community-acquired diarrhea in a tertiary care center in Lebanon

Clostridium difficile infection (CDI) is becoming a cause of community-acquired diarrhea. The aim is to describe (CDI) as a cause of acute diarrhea in patients presenting from the community to the Emergency Department (ED) of a tertiary care center in Lebanon. A retrospective study conducted in the ED at the American University of Beirut Medical Center (AUBMC). Adult patients presenting with the chief complaint of diarrhea and having positive CDI by stool laboratory testing (toxins A and B), during a three-year period were included. 125 patients with CDI were included. Average age was 61.43 (±20.42) with roughly equal sex prevalence. 30% (n = 36) of patients had neither antibiotic exposure nor recent hospitalization prior to current CDI. Mortality was 9.6% (n = 12), CDI was attributed as the cause in 16.7% (n = 2) and a contributing factor in 41.6% (n = 5). Recurrence within 3 months occurred in 9.6% (n = 11) in mainly those taking Proton Pump Inhibitors (PPIs) and having multiple co-morbidities. There is a high rate of community acquired CDI in Lebanon. Review of patients’ medications (PPIs and antibiotics) is crucial. More studies are needed to assess mortality associated with CDI and the outcome of coinfection with other enteric pathogens.

Epidemiological Aspects of Clostridium Difficile Infection in the Southeast Region of Romania

Clostridium difficile infection (CDI) in Galati county is an very important public health problem, the number of cases per 100 outpatients being in the first 5, nationally. The percentage of community-associated infection in this county is higher than the national and european ones. We performed a prospective observational study on 720 patients admitted between 1.01.2017-31.12.2018 in the Clinical Hospital of Infectious Diseases „St. Cuv. Parascheva“ Galati and we analyzed comparative demographic data, risk factors, disease evolution and prognosis of a batch of 565 (78.47%) patients with healthcare facility associated infection, with a batch of 144 patients (20%) with community-associated infection. The identified type of Clostridium difficile was ribotype 027 in 93.61% of the toxigenic strains studied. The study showed that CDI predominantly affects women in urban areas. Patients with community source are younger, with less comorbidities, have episodes of illness with lower severity and better prognosis both in terms of CDI recurrence and post-CDI death. Patients with a nosocomial source are older, with multiple comorbidities, with greater exposure to antibiotic, proton pump inhibitor and recent abdominal surgery, have severe episodes of the disease and have a poorer prognosis than those with a community source.

Clostridium difficile infection: Is there a change in the underlying factors? Inflammatory bowel disease and Clostridium difficile

BACKGROUND / AIMS

Clostridium difficile is a Gram-positive, strict anaerobe, spore-forming bacterium. It can cause self-limiting mild diarrhea, severe diarrhea, pseudomembranous colitis, and fatal fulminant colitis. We aimed to investigate the changes in epidemiology and incidence of C. difficile infection in our hospital database.

PATIENTS AND METHODS

Episodes of C. difficile toxin were identified in hospital database, and data such as age, sex, community versus hospital acquisition, intensive care follow-up, current or previous treatments with antibiotics within the past 3 months, medication with proton pump inhibitors, or immunosuppressive therapies were collected.

RESULTS

Toxin-positive 78 individuals constituted the patient group. In univariate analyses, independent risk factors for toxin positivity were community versus hospital acquisition [odds ratio (OR), 5.49; 95% confidence interval (CI), 2.52-11.95; P = 0.0001], presence of inflammatory bowel diseases (IBDs) (OR, 21.5; 95% CI, 8.65-53.44; P = 0.0001), proton pump inhibitors' use (OR, 4.53; 95% CI, 1.97-10.43; P = 0.0001), immunosuppressive drug use (OR, 4.1; 95% CI, 2.01-8.3; P = 0.0001), and use of quinolone group of antibiotics (OR, 5.95; 95% CI, 1.92-18.46; P = 0.001). Antibiotic use was a protective risk factor (OR, 0.09; 95% CI, 0.01-0.78; P = 0.01) and presence of IBDs was an independent risk factor (OR, 6.8; 95% CI, 1.5-30.08; P = 0.01) in community-acquired group (OR, 0.09; 95% CI, 0.01-0.78; P = 0.01).

CONCLUSION

In recent studies, C. difficile infections were demonstrated to be more frequent in younger individuals who did not have a history of hospitalization but had an underlying disease such as IBD. In our study, we showed the change in the epidemiological data with prominence of underlying diseases such as IBDs.

Clostridioides difficile infection: Incidence and risk factors in a tertiary care facility in Riyadh, Saudi Arabia

BACKGROUND

Significant increase in rates of Clostridioides difficile associated diarrhea (CDI) has been reported globally but there remains a paucity of data from Saudi Arabia.

METHODOLOGY

Prospective hospital-based surveillance for CDI using the Center for Disease Control (CDC) criteria was conducted from June to November 2015 in a tertiary healthcare facility in Riyadh, Saudi Arabia.

RESULTS

During the surveillance period, 106 episodes of CDI were identified among 59 patients in 137,230 patient-days. The incidence of CDI was 3.5 per 10,000 patient days. Of the 106 episodes, 58% (n=61) were new cases, 12% (n=13) were recurrent cases and 30% (n=32) were duplicate cases. Majority of the new cases (n/N=43/61; 70%) were healthcare onset, followed by community onset (21%) and 8% were community-onset healthcare associated. No statistically significant change in trend was observed during the surveillance period. The most prevalent CDI risk factor was use of proton pump inhibitor (PPI) (92%) followed by prolonged use of antibiotics (77%). Pareto-analysis indicated that controlling for PPI use, prolong and multiple antibiotic exposure and prolonged hospitalization results in 80% CDI reduction.

CONCLUSION

The findings indicate a low incidence of CDI. Multicenter studies are needed to elucidate the burden to CDI in the country.

Epidemiologic Trends in Clostridioides difficile Infections in a Regional Community Hospital Network

IMPORTANCE

Clostridioides difficile infection (CDI) remains a leading cause of health care facility-associated infection. A greater understanding of the regional epidemiologic profile of CDI could inform targeted prevention strategies.

OBJECTIVES

To assess trends in incidence of health care facility-associated and community-acquired CDI among hospitalized patients over time and to conduct a subanalysis of trends in the NAP1 strain of CDI over time.

DESIGN, SETTING, AND PARTICIPANTS

This long-term multicenter cohort study reviewed records of patients (N = 2 025 678) admitted to a network of 43 regional community hospitals primarily in the southeastern United States from January 1, 2013, through December 31, 2017. Generalized linear mixed-effects models were used to adjust for potential clustering within facilities and changing test method (nucleic acid amplification testing or toxin enzyme immunoassay) over time.

MAIN OUTCOMES AND MEASURES

Clostridioides difficile infection incidence rates were counted as cases per 1000 admissions for community-acquired and total CDI cases or cases per 10 000 patient-days for health care facility-associated CDI. Long-term trends in the proportion of cases acquired in the community and in NAP1 strain incidence were also evaluated.

RESULTS

A total of 2 025 678 admissions and 21 254 CDI cases were included (12 678 [59.6%] female; median [interquartile range] age, 69 [55-80] years). Median (interquartile range) total CDI incidence increased slightly from 7.9 (3.5-12.4) cases per 1000 admissions in 2013 to 9.3 (4.9-13.7) cases per 1000 admissions in 2017. After adjustment, the overall incidence of health care facility-associated CDI declined (incidence rate ratio [IRR], 0.995; 95% CI, 0.990-0.999; P = .03), whereas insufficient evidence was found for either an increase or a decrease in community-acquired CDI (IRR, 1.004; 95% CI, 0.999-1.009; P = .14). The proportion of cases classified as community acquired increased over time from a mean (SD) of 0.49 (0.28) in 2013 to 0.61 (0.26) in 2017 (odds ratio, 1.010 per month; 95% CI, 1.006-1.015; P < .001). Rates of the NAP1 strain of CDI varied widely between facilities, with no statistically significant change in NAP1 strain incidence over time in the community setting (IRR, 1.007; 95% CI, 0.994-1.021) or health care facility setting (IRR, 1.011; 95% CI, 0.990-1.032).

CONCLUSIONS AND RELEVANCE

The findings suggest that, despite the modest improvement in health care facility-associated CDI rates, a better understanding of community-acquired CDI incidence is needed for future infection prevention efforts.

Genomic Delineation of Zoonotic Origins of Clostridium difficile

Clostridium difficile is toxin-producing antimicrobial resistant (AMR) enteropathogen historically associated with diarrhea and pseudomembranous colitis in hospitalized patients. In recent years, there have been dramatic increases in the incidence and severity of C. difficile infection (CDI), and associated morbidity and mortality, in both healthcare and community settings. C. difficile is an ancient and diverse species that displays a sympatric lifestyle, establishing itself in a range of ecological niches external to the healthcare system. These sources/reservoirs include food, water, soil, and over a dozen animal species, in particular, livestock such as pigs and cattle. In a manner analogous to human infection, excessive antimicrobial exposure, particularly to cephalosporins, is driving the expansion of C. difficile in livestock populations worldwide. Subsequent spore contamination of meat, vegetables grown in soil containing animal feces, agricultural by-products such as compost and manure, and the environment in general (households, lawns, and public spaces) is contributing to a persistent community source/reservoir of C. difficile and the insidious rise of CDI in the community. The whole-genome sequencing era continues to redefine our view of this complex pathogen. The application of high-resolution microbial genomics in a One Health framework (encompassing clinical, veterinary, and environment derived datasets) is the optimal paradigm for advancing our understanding of CDI in humans and animals. This approach has begun to yield critical insights into the genetic diversity, evolution, AMR, and zoonotic potential of C. difficile. In Europe, North America, and Australia, microevolutionary analysis of the C. difficile core genome shows strains common to humans and animals (livestock or companion animals) do not form distinct populations but share a recent evolutionary history. Moreover, for C. difficile sequence type 11 and PCR ribotypes 078 and 014, major lineages of One Health importance, this approach has substantiated inter-species clonal transmission between animals and humans. These findings indicate either a zoonosis or anthroponosis. Moreover, they challenge the existing paradigm and the long-held misconception that CDI is primarily a healthcare-associated infection. In this article, evolutionary, and zoonotic aspects of CDI are discussed, including the anthropomorphic factors that contribute to the spread of C. difficile from the farm to the community.

Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection

In recent decades, Clostridium difficile infection (CDI) has become a worldwide health problem. Mexico is no exception, and therefore the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, endoscopists, internists, infectious disease specialists, and microbiologists) to carry out the "Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection", establishing useful recommendations (in relation to the adult population) for the medical community. Said recommendations are presented herein. Among them, it was recognized that CDI should be suspected in subjects with diarrhea that have a history of antibiotic and/or immunosuppressant use, but that it can also be a community-acquired infection. A 2-step diagnostic algorithm was proposed, in which a highly sensitive test, such as glutamate dehydrogenase (GDH), is first utilized, and if positive, confirmed by the detection of toxins through immunoassay or nucleic acid detection tests. Another recommendation was that CDI based on clinical evaluation be categorized as mild-moderate, severe, and complicated severe, given that such a classification enables better therapeutic decisions to be made. In mild-moderate CDI, oral vancomycin is the medication of choice, and metronidazole is recommended as an alternative treatment. In addition, fecal microbiota transplantation was recognized as an efficacious option in patients with recurrence or in the more severe cases of infection, and surgery should be reserved for patients with severe colitis (toxic megacolon), in whom all medical treatment has failed.

Carriage and colonization of C. difficile in preterm neonates: A longitudinal prospective study

Background

Premature neonates (PN) present multiple risk factors for high frequencies and high levels of colonization by C. difficile, yet data is missing about this specific pediatric population. Here, we investigated PN C. difficile carriage and colonization dynamics, analyzed the impact of perinatal determinants on colonization, and characterized the isolates.

Methods

A one year longitudinal monocentric prospective cohort study was performed on 121 PN. C. difficile strains isolated from fecal samples on selective medium were identified and characterized by PCR (tpi housekeeping gene; tcdA and tcdB, and binary toxin genes), capillary gel-based electrophoresis PCR-ribotyping, and Multi-Locus Variable-number tandem-repeat Analysis (MLVA).

Results

Of the 379 samples analyzed, 199 (52%) were C. difficile culture positive with the mean levels of C. difficile colonization decreasing significantly (P = .027) over time. During hospitalization, C. difficile colonization frequency increased up to 61% with 95% of the strains belonging to both non-toxigenic PCR-ribotypes (RTs) FR082 (35%) and 032 (60%). After hospital discharge, if a higher diversity in RTs was observed, RTs FR082 and 032 remained predominant (respectively 40% and 28%). MLVA showed clonal relationship within each FR082 and 032 RTs. Ten toxigenic strains (5%) were isolated, all tcdA⁺/tcdB⁺ except for one tcdA^-/tcdB⁺, and all being acquired after hospitalization. At 1 week, the only factors found to be linked with a higher frequency of C. difficile colonization were a higher gestational age (P = 0.006) and a higher birth weight (P = 0.016).

Conclusion

The dynamics of C. difficile colonization in PN followed a specific pattern. C. difficile colonization rapidly occurred after birth with a low diversity of non-toxigenic RTs. After hospitalization, non-toxigenic RTs diversity increased. Sporadic carriage of toxigenic strains was observed after hospitalization.

Global burden of Clostridium difficile infections: a systematic review and meta-analysis

Background

Clostridium difficile is a leading cause of morbidity and mortality in several countries. However, there are limited evidence characterizing its role as a global public health problem. We conducted a systematic review to provide a comprehensive overview of C. difficile infections (CDI) rates.

Methods

Seven databases were searched (January 2016) to identify studies and surveillance reports published between 2005 and 2015 reporting CDI incidence rates. CDI incidence rates for health care facility-associated (HCF), hospital onset-health care facility-associated, medical or general intensive care unit (ICU), internal medicine (IM), long-term care facility (LTCF), and community-associated (CA) were extracted and standardized. Meta-analysis was conducted using a random effects model.

Results

229 publications, with data from 41 countries, were included. The overall rate of HCF-CDI was 2.24 (95% confidence interval CI = 1.66-3.03) per 1000 admissions/y and 3.54 (95%CI = 3.19-3.92) per 10 000 patient-days/y. Estimated rates for CDI with onset in ICU or IM wards were 11.08 (95%CI = 7.19-17.08) and 10.80 (95%CI = 3.15-37.06) per 1000 admission/y, respectively. Rates for CA-CDI were lower: 0.55 (95%CI = 0.13-2.37) per 1000 admissions/y. CDI rates were generally higher in North America and among the elderly but similar rates were identified in other regions and age groups.

Conclusions

Our review highlights the widespread burden of disease of C. difficile, evidence gaps, and the need for sustainable surveillance of CDI in the health care setting and the community.

Toxigenic Clostridium difficile carriage in general practice: results of a laboratory-based cohort study

OBJECTIVES

Reported rates of community-acquired Clostridium difficile infections (CDIs) have been increasing. However, the true burden of the disease in general practice is unknown in France. Our objective was to determine the incidence of toxigenic C. difficile carriage and the percentage of stool samples prescribed by general practitioners (GPs) which contained free C. difficile toxins.

METHODS

During an 11-month period, all stool samples submitted for any enteric pathogen detection to 15 different private laboratories in Paris and the surrounding areas were tested for C. difficile, irrespective of the GPs' request. A clinical questionnaire was completed for each patient. Stool samples were screened using a rapid simultaneous glutamate dehydrogenase and toxins A/B detection test: any positive result (glutamate dehydrogenase or toxin) was further confirmed by the stool cytotoxicity assay (CTA) on MRC-5 cells and by toxigenic culture (TC) at a central laboratory. The C. difficile isolates were characterized by PCR ribotyping.

RESULTS

A total of 2541 patients (1295 female, 1246 male) were included. The incidences of patients with a positive toxigenic culture and a positive CTA were 3.27% (95% CI 2.61%-4.03%) and 1.81% (95% CI 1.33%-2.41%), respectively. GPs requested C. difficile testing in only 12.93% of the stool samples, detecting 52.30% of all TC-positive patients. The 83 toxigenic C. difficile strains belonged to 36 different PCR ribotypes.

CONCLUSIONS

Toxigenic C. difficile carriage is frequent in general practice but remains under-recognized. It may affect young patients without previous antimicrobial therapy or hospitalization.

Clostridium difficile infection in Johannesburg, South Africa

OBJECTIVES

The incidence of Clostridium difficile infection is increasing, resulting in significant in-patient morbidity and mortality. We describe the characteristics of Clostridium difficile infection in patients admitted to a tertiary Academic Hospital in Johannesburg, South Africa.

METHODS

This was a retrospective record review of 154 adult in-patients with confirmed Clostridium difficile infection undertaken between 1 January 2013 and 30 June 2014.

RESULTS

Overall, 83 (53.9%) patients were female and the median age was 39 years. The most common symptoms were watery diarrhea (92.9%) and fever (27.3%). Overall, 145 (97.9%) patients had been exposed to antibiotics in the last 30 days, 54 (35.1%) to immunosuppressives, 48 (31.2%) to gastric acid suppressants, and 65 (42.2%) patients had previous hospital admissions. Only two cases were community-acquired. In total, 73 (47.4%) patients died. There was no difference in outcomes of HIV-positive patients compared to HIV-negative patients; however, the clinical features were more marked in the HIV-negative patients. Non-survivors tended to have a greater number of severity indicators compared to the survivors.

CONCLUSION

Patients with Clostridium difficile infection in this study were younger and had a higher mortality than that reported in the Western world. Most infections were hospital-acquired.

Prevalence and Molecular Characteristics of Clostridium difficile in Retail Meats, Food-Producing and Companion Animals, and Humans in Minnesota

Community-associated Clostridium difficile infection (CA-CDI) now accounts for approximately 50% of CDI cases in central Minnesota; animals and meat products are potential sources. From November 2011 to July 2013, we cultured retail meat products and fecal samples from food-producing and companion animals in central Minnesota for C. difficile by using standard methods. The resulting 51 C. difficile isolates, plus 30 archived local veterinary C. difficile isolates and 208 human CA-CDI case isolates from central Minnesota (from 2012) from the Minnesota Department of Health, were characterized molecularly, and source groups were compared using discriminant analysis. C. difficile was recovered from 0 (0%) of 342 retail meat samples and 51 (9%) of 559 animal fecal samples. Overall, the 81 animal source isolates and 208 human source isolates were highly diverse genetically. Molecular traits segregated extensively in relation to animal versus human origin. Discriminant analysis classified 95% of isolates correctly by source group; only five (2.5%) human source isolates were classified as animal source. These data do not support meat products or food-producing and companion animals as important sources of CA-CDI in the central Minnesota study region.

Epidemiological and genomic characterization of community-acquired Clostridium difficile infections

BACKGROUND

Clostridium difficile infection (CDI) is a major cause of morbidity and mortality in North America and Europe. The aim of this study was to identify epidemiologically-confirmed cases of community-acquired (CA)-CDI in a large North American urban center and analyze isolates using multiple genetic and phenotypic methods.

METHODS

Seventy-eight patients testing positive for C. difficile from outpatient clinics were further investigated by telephone questionnaire. CA-CDI isolates were characterized by antibiotic susceptibility, pulsed-field gel electrophoresis and whole genome sequencing. CA-CDI was defined as testing positive greater than 12 weeks following discharge or no previous hospital admission in conjunction with positive toxin stool testing.

RESULTS

51.3% (40/78) of the patients in this study were found to have bona fide CA-CDI. The majority of patients were female (71.8% vs. 28.2%) with 50-59 years of age being most common (21.8%). Common co-morbidities included ulcerative colitis (1/40; 2.5%), Crohn's disease (3/40; 7.5%), celiac disease (2/40; 5.0%) and irritable bowel syndrome (8/40; 20.0%). However, of 40 patients with CA-CDI, 9 (29.0%) had been hospitalized between 3 and 6 months prior and 31 (77.5%) between 6 and 12 months prior. The hypervirulent North American Pulostype (NAP) 1-like (9/40; 22.5%) strain was the most commonly identified pulsotype. Whole genome sequencing of CA-CDI isolates confirmed that NAP 1-like pulsotypes are commonplace in CA-CDI. From a therapeutic perspective, there was universal susceptibility to metronidazole and vancomycin.

CONCLUSIONS

All CA-CDI cases had some history of hospitalization if the definition were modified to health care facility exposure in the last 12 months and is supported by the genomic analysis. This raises the possibility that even CA-CDI may have nosocomial origins.

Spatial clustering and livestock exposure as risk factor for community-acquired Clostridium difficile infection

OBJECTIVES

Clostridium difficile infections (CDI) account for 1.5% of diarrhoeic episodes in patients attending a general practitioner in the Netherlands, but its sources are unknown. We searched for community clusters to recognize localized point sources of CDI.

METHODS

Between October 2010 and February 2012, a community-based prospective nested case-control study was performed in three laboratories in the Netherlands with a study population of 2 810 830 people. Bernoulli spatial scan and space-time permutation models were used to detect spatial and/or temporal clusters of CDI. In addition, a multivariate conditional logistic regression model was constructed to test livestock exposure as a supposed risk factor in CDI patients without hospital admission within the previous 12 weeks (community-acquired (CA) CDI).

RESULTS

In laboratories A, B and C, 1.3%, 1.8% and 2.1% of patients with diarrhoea tested positive for CDI, respectively. The mean age of CA-CDI patients (n = 124) was 49 years (standard deviation, 22.6); 64.5% were female. No spatial or temporal clusters of CDI cases were detected compared to C. difficile-negative diarrhoeic controls. Except for one false-positive signal, no spatiotemporal interaction amongst CDI cases was found. Livestock exposure was not related to CA-CDI (odds ratio, 0.99; 95% confidence interval, 0.44-2.24). Ten percent of CA-CDIs was caused by PCR ribotype 078, spatially dispersed throughout the study area.

CONCLUSIONS

The absence of clusters of CDI cases in a community cohort of diarrhoeic patients suggests a lack of localized point sources of CDI in the living environment of these patients.

Reducing risk of Clostridium difficile infection and overall use of antibiotic in the outpatient treatment of urinary tract infection

Background

Risk of community-acquired Clostridium difficile infection (CA-CDI) following antibiotic treatment specifically for urinary tract infection (UTI) has not been evaluated.

Methods

We conducted a nested case-control study at Kaiser Permanente Northern California, 2007-2010, to assess antibiotic prescribing and other factors in relation to risk of CA-CDI in outpatients with uncomplicated UTI. Cases were diagnosed with CA-CDI within 90 days of antibiotic use. We used matched controls and confirmed case-control eligibility through chart review. Antibiotics were classified as ciprofloxacin (most common), or low risk (nitrofurantoin, sulfamethoxazole/trimethoprim), moderate risk, or high risk (e.g. cefpodoxime, ceftriaxone, clindamycin) for CDI. We computed the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the relationship of antibiotic treatment for uncomplicated UTI and history of relevant gastrointestinal comorbidity (including gastrointestinal diagnoses, procedures, and gastric acid suppression treatment) with risk of CA-CDI using logistic regression analysis.

Results

Despite the large population, only 68 cases were confirmed with CA-CDI for comparison with 112 controls. Female sex [81% of controls, adjusted odds ratio (OR) 6.3, CI 1.7-24), past gastrointestinal comorbidity (prevalence 39%, OR 2.3, CI 1.1-4.8), and nongastrointestinal comorbidity (prevalence 6%, OR 2.8, CI 1.4-5.6) were associated with increased CA-CDI risk. Compared with low-risk antibiotic, the adjusted ORs for antibiotic groups were as follows: ciprofloxacin, 2.7 (CI 1.0-7.2); moderate-risk antibiotics, 3.6 (CI 1.2-11); and high-risk antibiotics, 11.2 (CI 2.4-52).

Conclusions

Lower-risk antibiotics should be used for UTI whenever possible, particularly in patients with a gastrointestinal comorbidity. However, UTI can be managed through alternative approaches. Research into the primary prevention of UTI is urgently needed.

Economic Burden of Clostridium difficile Infection in European Countries

Clostridium difficile infection (CDI) remains a considerable challenge to health care systems worldwide. Although CDI represents a significant burden on healthcare systems in Europe, few studies have attempted to estimate the consumption of resources associated with CDI in Europe. The reported extra costs attributable to CDI vary widely according to the definitions, design, and methodologies used, making comparisons difficult to perform. In this chapter, the economic burden of healthcare facility-associated CDI in Europe will be assessed, as will other less explored areas such as the economic burden of recurrent CDI, community-acquired CDI, pediatric CDI, and CDI in outbreaks.

The CDI-DaySyms: Content Development of a New Patient-Reported Outcome Questionnaire for Symptoms of Clostridium difficile Infection

OBJECTIVES

To develop a patient-reported outcome (PRO) questionnaire for symptoms of Clostridium difficile infection (CDI) following the US Food and Drug Administration PRO guidelines.

METHODS

Patients' experiences of CDI symptoms were elicited in open-ended discussions with patients and nurses at five US sites (stage 1). A draft PRO measure was developed after demonstration of concept saturation. Two rounds of cognitive interviews were conducted with patients at three US sites (stage 2), with revision of the draft measure after each round. All patients were 18 years or older, with confirmed CDI. The study was conducted with input from a panel of five CDI experts in Europe and North America.

RESULTS

Stage 1 included interviews with 18 patients and supplementary interviews with 6 nurses; 16 additional patients were interviewed in stage 2. Patients were representative of the general CDI population and were diverse in age, sex, and disease severity. Concept saturation was reached in stage 1. Items were organized in a draft conceptual framework with five hypothesized domains: diarrhea, abdominal discomfort, tiredness, lightheadedness, and other symptoms. Stage 2 demonstrated initial content validity of the 13-item draft daily diary (CDI-DaySyms). Participants reported that the questions were clear, relevant, and comprehensive. They were able to use the instructions to complete the diary correctly and considered the 24-hour recall period appropriate.

CONCLUSIONS

The CDI-DaySyms captures symptoms relevant to patients undergoing CDI, demonstrating initial content validity. Final content and psychometric validity are being evaluated in a substudy comprising patients from two ongoing international clinical trials (ClinicalTrials.gov identifiers NCT01987895 and NCT01983683).

Shift to community-onset Clostridium difficile infection in the national Veterans Health Administration, 2003-2014

BACKGROUND

Clostridium difficile infection (CDI) occurs frequently in inpatient settings; however, community-onset cases have been reported more frequently in recent years. This study evaluated hospital-onset and community-onset CDI in the national Veterans Health Administration (VHA) population over a 12-year period.

METHODS

This was a retrospective cohort study of all adult VHA beneficiaries with CDI between October 1, 2002, and September 30, 2014. Data were obtained from the Veterans Affairs Informatics and Computing Infrastructure. CDI was categorized into community-associated CDI (CA-CDI); community-onset, health care facility-associated CDI; and health care facility-onset CDI (HCFO-CDI). Each type was described longitudinally and was assessed as an independent risk factor for health outcomes using multivariable logistic regression.

RESULTS

Overall, 30,326 patients with a first CDI episode were included. HCFO-CDI was the predominant type (60.2%), followed by CO-HCFA-CDI (20.6%) and CA-CDI (19.2%). The proportion of patients with HCFO-CDI decreased from 73.5% during fiscal year 2003 to 53.2% during fiscal year 2014, whereas CA-CDI increased from 8.3% to 26.7%. HCFO-CDI was a positive predictor of severe CDI (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.59-1.84) and 30-day mortality (OR, 1.46; 95% CI, 1.32-1.61), but a negative predictor of 60-day recurrence (OR, 0.41; 95% CI, 0.37-0.46).

CONCLUSIONS

HCFO-CDI was the predominant CDI type. The proportion of patients with CA-CDI increased and HCFO-CDI decreased in recent years. Patients with HCFO-CDI experienced higher rates of severe CDI and mortality.

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.

Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study

BACKGROUND

An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors.

METHODS

We enrolled participants from 10 US sites during October 2014-March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed.

RESULTS

Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure-that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13-321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01-311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77-340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76-340.05),-emergency department visit (AmOR, 17.37; 95% CI, 1.99-151.22), white race (AmOR 7.67; 95% CI, 2.34-25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20-19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24-118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27-20.79) were associated with CA-CDI.

CONCLUSIONS

Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed.

Clostridium difficile in Inflammatory Bowel Disease: A Retrospective Study

Aim

To investigate the epidemiology and risk factors of Clostridium difficile infections (CDI) in patients with inflammatory bowel disease (IBD).

Methods

This is a retrospective study of patients diagnosed with IBD. 1006 charts were screened and 654 patients met the inclusion criteria. Patients were divided into 2 cohorts based on the presence of prior diagnosis of CDI. Statistical analysis with Pearson's chi-squared and two-sample t-test was performed.

Results

The incidence of CDI among IBD patients was 6.7%. There was equal prevalence of CDI among Crohn's disease (CD) (n = 21, 49%) and ulcerative colitis (UC) (n = 22, 51%). IBD patients acquired CDI at a mean age of 42.7 years, with 56% of infections acquired in the community and only 28% associated with healthcare. Only 30% of IBD patients with CDI had prior antibiotic use, and 16% had prior steroid use. IBD patients were significantly more likely to require biologic therapy (57% versus 37%, p < 0.01) and have extraintestinal manifestations of IBD (43% versus 28%, p < 0.02).

Conclusions

IBD patients are more susceptible to CDI at a younger age and often lack traditional risk factors. IBD patients with at least one CDI were more likely to require biologic therapy and had greater rates of extraintestinal manifestations.

Proton pump inhibitors therapy and risk of Clostridium difficile infection: Systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on proton pump inhibitors (PPIs) therapy and the risk of Clostridium difficile infection (CDI).

METHODS

We conducted a systematic search of MEDLINE/PubMed and seven other databases through January 1990 to March 2017 for published studies that evaluated the association between PPIs and CDI. Adult case-control and cohort studies providing information on the association between PPI therapy and the development of CDI were included. Pooled odds ratios (ORs) estimates with 95% confidence intervals (CIs) were calculated using the random effect. Heterogeneity was assessed by I² test and Cochran’s Q statistic. Potential publication bias was evaluated via funnel plot, and quality of studies by the Newcastle-Otawa Quality Assessment Scale (NOS).

RESULTS

Fifty-six studies (40 case-control and 16 cohort) involving 356683 patients met the inclusion criteria and were analyzed. Both the overall pooled estimates and subgroup analyses showed increased risk for CDI despite substantial statistical heterogeneity among studies. Meta-analysis of all studies combined showed a significant association between PPI users and the risk of CDI (pooled OR = 1.99, CI: 1.73-2.30, P < 0.001) as compared with non-users. The association remained significant in subgroup analyses: by design-case-control (OR = 2.00, CI: 1.68-2.38, P < 0.0001), and cohort (OR = 1.98, CI: 1.51-2.59, P < 0.0001); adjusted (OR = 1.95, CI: 1.67-2.27, P < 0.0001) and unadjusted (OR = 2.02, CI: 1.41-2.91, P < 0.0001); unicenter (OR = 2.18, CI: 1.72-2.75, P < 0.0001) and multicenter (OR = 1.82, CI: 1.51-2.19, P < 0.0001); age ≥ 65 years (OR = 1.93, CI: 1.40-2.68, P < 0.0001) and < 65 years (OR = 2.06, CI: 1.11-3.81, P < 0.01). No significant differences were found in subgroup analyses (test for heterogeneity): P = 0.93 for case-control vs cohort, P = 0.85 for adjusted vs unadjusted, P = 0.24 for unicenter vs multicenter, P = 0.86 for age ≥ 65 years and < 65 years. There was significant heterogeneity across studies (I² = 85.4%, P < 0.001) as well as evidence of publication bias (funnel plot asymmetry test, P = 0.002).

CONCLUSION

This meta-analysis provides further evidence that PPI use is associated with an increased risk for development of CDI. Further high-quality, prospective studies are needed to assess whether this association is causal.