Clostridium difficile Strain NAP-1 Is Not Associated With Severe Disease in a Nonepidemic Setting

Abstract

Recent outbreaks of Clostridium difficile infection (CDI) in North America and in Europe with very high case-fatality rates have been associated with infection by North American Pulsed Field Type I (NAP-1) isolates. This study examined whether NAP-1 strains are associated with worse outcomes of CDI in a nonepidemic, nosocomial setting. All cases of CDI that occurred over a 13-month period at a tertiary medical center were examined for risk factors associated with increased severity of CDI and other outcomes. Stool samples from each patient were cultured for C difficile and the resulting isolates were strain-typed by pulsed-field gel electrophoresis. Strain types were obtained from 236 of 272 CDI samples; the NAP-1 strain was identified in 59 (25%). In this inpatient cohort of patients with CDI, the incidence of in hospital death was 12.1% and of death caused by CDI was 4.0%. Of the patients with CDI, 22.1% met the combined outcome end point of severe CDI. In both univariate and multivariate analyses, patients infected with the NAP-1 strain did not have worse outcomes compared with those infected with non-NAP-1 strains. Infection with the NAP-1 strain was correlated with admission from outside health care facilities regardless of whether symptoms of CDI began before or after admission to the study hospital. The NAP-1 strain of C difficile was found to cause 25% of cases of CDI in the hospital where the study was performed. However, compared with non-NAP-1 strains, CDI was not associated with increased severity of disease in this nonepidemic setting.