Changing incidence and clinical manifestations of Clostridium difficile-associated diarrhea detected by combination of glutamate dehydrogenase and toxin assay in Northern Taiwan

Abstract

The incidence of Clostridium difficile-associated diarrhea (CDAD) is increasing worldwide. Spread of an epidemic hypervirulent strain in southern Taiwan was associated with poor outcome. This prospective study evaluates the incidence and clinical manifestation of CDAD following a hospital-wide hand hygiene promotion program in a 2,200-bed teaching hospital in northern Taiwan. From June 1, 2010 to October 31, 2010, a predefined protocol was used to actively survey CDAD at 11 high-risk units. Stool samples of patients with antibiotic-associated diarrhea (AAD) were submitted for stool culture and toxin A/B assay using a combined enzyme immunoassay. CDAD was diagnosed by a positive toxin assay. The incidence of CDAD was 0.45/1000 patient-days and was highest in medical intensive care units (7.9/1000 patient-days), followed by hemato-oncology wards, and infectious disease wards. Occurrence of CDAD was associated with ≥3 stool pus cells per high power field (p=0.018), prior use of metronidazole (p=0.029), high usage of beta-lactamase stable penicillins (p=0.046), and anaerobe-active antibiotics (p=0.029). No attributable mortality was found. The incidence of CDAD was lower than that previously observed (1.0/1000 patient-days in 2003, p<0.001). This study showed a lower incidence of CDAD and absence of attributable mortality. The impact of hand hygiene promotion and other infection control measures on decreasing incidence of CDAD warrants further elucidation.