Factors associated with an outbreak of hospital-onset, healthcare facility-associated Clostridium difficile infection (HO-HCFA CDI) in a Mexican tertiary care hospital: A case-control study.

Eric Ochoa-Hein,Víctor Granados-García,Pedro Torres-González,Arturo Galindo-Fraga,José Sifuentes-Osornio,Alfredo Ponce De León-Garduño,Abhishek Deshpande

doi:10.1371/journal.pone.0198212

Abstract

ObjectiveTo identify clinical and environmental factors associated with an outbreak of hospital-onset, healthcare facility-associated Clostridium difficile infection (HO-HCFA CDI).DesignCase-control study.SettingPublic, acute care, academic tertiary referral center in Mexico.PatientsAdults hospitalized ≥48 hours between January 2015 and December 2016 were included. Cases were patients with a first episode of HO-HCFA CDI. Controls were patients with any other diagnosis; they were randomly selected from the hospital discharge database and matched in a 1:2 manner according to the date of diagnosis of case ± 10 days. Variables with p<0.1 were considered for multivariable analysis.ResultsOne hundred and fifty-five cases and 310 controls were included. Variables independently associated with HO-HCFA CDI were: exposure to both ciprofloxacin and proton pump inhibitor (PPI) within the last 3 months (OR = 8.07, 95% CI = 1.70–38.16), febrile neutropenia (OR = 4.61, 95% CI = 1.37–15.46), intraabdominal infection (OR = 2.06, 95% CI = 0.95–4.46), referral from other hospitals (OR = 1.99, 95% CI = 0.98–4.05) and an increasing number of antibiotics previously used (OR = 1.28, 95% CI = 1.13–1.46).ConclusionsMultiple factors were found to be associated with the first episode of HO-HCFA CDI in the setting of an outbreak; of the modifiable risk factors, prior exposure to both ciprofloxacin and PPI was the most important. Referral from other hospitals was an environmental risk factor that deserves further study.

Highlights

The burden imposed by Clostridium difficile infection (CDI) on hospitals and communities is dangerously increasing worldwide [1]
Variables independently associated with HO-HCFA CDI were: exposure to both ciprofloxacin and proton pump inhibitor (PPI) within the last 3 months (OR = 8.07, 95% confidence intervals (95% CI) = 1.70–38.16), febrile neutropenia (OR = 4.61, 95% CI = 1.37–15.46), intraabdominal infection
Multiple factors were found to be associated with the first episode of HO-HCFA CDI in the setting of an outbreak; of the modifiable risk factors, prior exposure to both ciprofloxacin and PPI was the most important

Summary

Introduction

The burden imposed by Clostridium difficile infection (CDI) on hospitals and communities is dangerously increasing worldwide [1]. CDI is the most frequent healthcare-associated infection and the main cause of gastroenteritis-associated death in the United States (107,600 hospital-onset infections and 29,000 related deaths in 2011, respectively) [1, 2]. Direct costs related to acute hospital care due to CDI are substantial ($4.8 billion in the United States in 2008) [1]. Some risk factors for CDI are well established, some differences between study populations have been noted. Carbapenems, piperacillin/tazobactam, ceftriaxone and vancomycin are frequently prescribed and are suspected to have a role in CDI risk, despite the fact that clindamycin and quinolones have been the main antibiotics historically associated with CDI. Some reports have shown that the environment plays an important role as a risk factor [7,8,9,10,11,12], but this has not been confirmed in all settings

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