Recurrence of Clostridium difficile infection in the Western Australian population.

M Alfayyadh,R Mccann,S Tempone,P K Armstrong,T V Riley,A Cook,D A Collins

doi:10.1017/s0950268819000499

Abstract

Clostridium difficile, the most common cause of hospital-associated diarrhoea in developed countries, presents major public health challenges. The high clinical and economic burden from C. difficile infection (CDI) relates to the high frequency of recurrent infections caused by either the same or different strains of C. difficile. An interval of 8 weeks after index infection is commonly used to classify recurrent CDI episodes. We assessed strains of C. difficile in a sample of patients with recurrent CDI in Western Australia from October 2011 to July 2017. The performance of different intervals between initial and subsequent episodes of CDI was investigated. Of 4612 patients with CDI, 1471 (32%) were identified with recurrence. PCR ribotyping data were available for initial and recurrent episodes for 551 patients. Relapse (recurrence with same ribotype (RT) as index episode) was found in 350 (64%) patients and reinfection (recurrence with new RT) in 201 (36%) patients. Our analysis indicates that 8- and 20-week intervals failed to adequately distinguish reinfection from relapse. In addition, living in a non-metropolitan area modified the effect of age on the risk of relapse. Where molecular epidemiological data are not available, we suggest that applying an 8-week interval to define recurrent CDI requires more consideration.

Highlights

Clostridium difficile, recently renamed Clostridiodes difficile [1], is a Gram-positive anaerobic bacillus and the most common cause of hospital-associated diarrhoea [2]
1102 isolates from initial and second episodes of C. difficile infection (CDI) were available from 551 patients, of which 350 (64%) were classified as relapse and 201 (36%) were classified as reinfection
Within the 8-week interval, the odds of relapse significantly exceeded those for infections arising beyond 8 weeks

Summary

Introduction

Clostridium difficile, recently renamed Clostridiodes difficile [1], is a Gram-positive anaerobic bacillus and the most common cause of hospital-associated diarrhoea [2]. C. difficile has the ability to establish itself in the digestive system after the normal gut flora have been altered, such as by exposure to antimicrobials. CDI is a complex disease and, with its potential to cause ongoing symptomatic disruptions to the normal flora of the digestive system, it is often difficult to determine if patients are experiencing a relapse in infection (originating from the same strain that caused initial episode) or a reinfection (caused by a new strain or the same strain) [9,10,11]. If infections cannot be correctly classified with a high degree of certainty, it becomes difficult to identify risk factors associated with different strains, evaluate treatment effects and correctly quantify the true burden of CDI in the community [12]

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