Clostridium Difficile Infection Cases Research Articles

Testing Stewardship: A ‘Hard Stop’ to Reduce Inappropriate C. diff Testing

BackgroundPatients may be over-diagnosed with C. difficile infection (CDI) due to colonization, especially if laxatives are used. We had implemented an alert to prompt providers to discontinue C. diff orders in the setting of laxative use. This initially decreased orders by about 25%, but became less effective over time. Our objective was to strengthen our C. diff testing stewardship by creating a “hard stop” to require providers to think critically about C. diff testing in the presence of laxative use or the absence of documented diarrhea.MethodsOur two-hospital, >1100-bed community-based academic healthcare system performs all C. diff testing via PCR. We implemented our initial laxative alert, which notified providers but did not prohibit testing, in March 2015. In April 2017, we launched a new alert that fired >36 hours after admission, and assessed for documented diarrhea (>2 episodes/24 hours). If diarrhea was present, it would assess for any administered laxative within prior 24 hours. If neither criterion was met, the provider could only order C. diff testing by calling the laboratory and documenting the staff person’s name in the order; no further justification was required. We measured the number of C. diff tests completed per day, the number of calls made to lab, and CDI rates (using NHSN LabID definition). Balancing measures included monitoring oral vancomycin orders without C. diff testing, and delayed CDI diagnoses.ResultsAt baseline, we observed a mean of 9 (SD, 4–14) C. diff orders daily. After initiating the hard stop alert, daily testing decreased by 30% (Fig. 1). Frequency of hospital-onset CDI dropped by 45% during first month of implementation (Fig. 2), from mean 3.6/week to 2/week. To date we have not detected delayed diagnoses or empiric treatment without testing; 18 override laboratory calls have been documented.ConclusionGiven PCR’s high sensitivity for C. diff, testing stewardship is critical to minimize false-positive cases of CDI, which lead to inappropriate treatment, prolonged length of stay, and hospital penalties. Requiring a phone call to order C. diff testing in the setting of laxative use or minimal diarrhea effectively reduced testing, and was well-accepted by nurses and providers. To date, no adverse effects have been detected.Disclosures All authors: No reported disclosures.

Incidence of Pediatric Community Associated Clostridium Difficile Infection Following Common Antibotics

BackgroundAs rates of pediatric community-associated (CA) Clostridium difficile infection (CDI) increase, additional research is needed to address rates of infection following common antibiotics.MethodsThis study was a retrospective review of the electronic health records of all children with stool specimens sent for C difficile from January first 2012 – December 31st2016 at Kaiser Permanente Northern California. Children with clinical symptoms consistent with CDI, confirmatory laboratory testing, no other identified causes of diarrhea, and community associated disease were defined as cases. Using outpatient and ED antibiotic prescription records for children, incidence rates were calculated for subsequent CA CDI for the most commonly prescribed antibiotics.ResultsOf 507 primary CDI cases in our cohort, 327 had any antibiotic use 2012–2015. There were 205 primary CDI cases that were preceded by an antibiotic in the previous 1–365 days. Many of these patients had more than 1 antibiotic in the preceding year.Of those, rates of CA CDI were uncommon following common antibiotics. (Table) The highest rate of CA CDI followed ceftriaxone, cefdinir, ciprofloxacin and augmentin. The lowest rates were seen following penicillin, doxycycline and azithromycin. Ninety-three percent of the antibiotic prescriptions were in outpatients, 7% in inpatients.Table: Incidence rate of CA CDI following common antibiotics Drug # Rx CA CDI cases with at least 1 prescription in last year Rate Rate per 100,000 Amoxicillin86,180380.000444Augmentin49,361350.000771Azithromycin160,846450.000328Cefdinir37,284360.001097Ceftriaxone10,616110.0010104Cefuroxime85210.0012117Cephalexin124,293550.000444Ciprofloxacin10,08890.000989Clindamycin79,884360.000545Doxycycline37,08680.000222Levofloxacin68710.0015146Penicillin19,48840.000221Rifampin486000Sulfamethoxazole TMP49,918340.000768Tetracycline6000 Total 667,075 205 0.0003 31 ConclusionAs rates of CA CDI increase, clinicians should be aware of rates of infection following administration of common antibiotics. The most common antibiotics to cause CA CDI were third-generation cephalosporins (ceftriaxone and cefdinir) and ciprofloxacin.Disclosures All authors: No reported disclosures.

Proton Pump Inhibitors Not a Major Risk Factor for Hospital-acquired Clostridium difficile Infection in Young, African American Males

Introduction: Clostridium difficile infection (CDI) is the leading cause of healthcare-associated infections. Due to its increased morbidity and mortality, there is great need to identify associated demographics and risk factors. National epidemiology reveals a predominance of elderly, Caucasian females. Proton pump inhibitors (PPIs) have been associated with a 1.4-2.75x increased risk of CDI. The exact relationship between hospital-acquired CDI (HA-CDI) and PPIs is unclear. We performed a retrospective analysis to (1) Examine CDI epidemiology at Hahnemann University Hospital compared to national epidemiology and (2) Investigate the association between PPIs as a risk factor for HA-CDI.Figure: Demographic and PPI characteristics of the CDI cases and controls.Methods: We conducted a case-control study of HA-CDI from 08/2014 to 04/2017. Cases (n=229) were defined as confrmed diagnosis 72 hrs post-admission. Controls (n=454) were frequency matched in a 2:1 ratio based on age and length of stay. PPI was classified into 4 categories: dosage (20mg, 40mg), frequency (QD, BID), delivery (PO, IV) and duration (10 days). Student's T-test, Wilcoxon rank sum test, Chisquared test were used to compare risk factors between cases and controls. Results: HA-CDI cases had a mean age of 60 with male predominance (54%, n=123) vs. females (46%, n=106), and by race, 56% (n=120) African American and 36% (n=77) Caucasian. In our sample (cases & controls), 48% (n=328) were on a PPI with the combined majority 73% (n=239) on 40mg daily vs. 25% (n=83) on 40mg BID. PPIs were administered orally in 61% (n=200) vs. IV in 38% (n=123) of all combined patients with the majority exposed for 10+ days (59%, n=190). There were no statistically significant differences between cases and controls in PPI use, dosage, route of administration or duration. Conclusion: National CDI epidemiology reveals a predominance of elderly (51.9% age >65), Caucasian (78.6%) and female (59%) patients. In contrast, our CDI epidemiology showed a predominance of younger, African American males. PPIs are theorized to increase the risk of CDI due to increased gastric pH which may prevent protective flora from actively suppressing the germination of Clostridium difficile spores and toxin synthesis. However, given that there was no significant association detected between PPI and CDI in our sample, we must consider alternative risk factors that may uniquely predispose our distinct cohort to CDI. The relationship between PPI and CDI in unique demographic cohorts such as ours needs to be further explored in future studies.

Are Patients with Prior Clostridium difficile Infection (CDI) a Potential Source of Transmission during Hospital Admissions?

BackgroundMany patients with Clostridium difficile infection (CDI) continue to shed spores asymptomatically after completion of CDI therapy. However, the duration of shedding and the potential for transmission during subsequent healthcare exposures is unknown.MethodsDuring a 6-month period, we collected perirectal, groin, and skin (chest/abdomen and hands) cultures for toxigenic C. difficile from patients with a prior history of CDI who were admitted to the hospital. We calculated the frequencies of perirectal and skin shedding of C. difficile at the time of admission, stratified by the time since the prior CDI diagnosis.ResultsOf 28 patients with a prior history of CDI enrolled in the study, 10 (36%) had positive perirectal cultures for toxigenic C. difficile upon admission, and 6 of 10 (60%) had positive skin cultures. The figure shows the percentages of CDI cases with positive perirectal, groin, or skin cultures, stratified by the time since the prior CDI diagnosis.ConclusionPatients with prior CDI often shed spores asymptomatically during hospital admissions. Further studies are needed to determine whether these carriers contribute significantly to transmission.FigurePercentages of CDI cases with positive perirectal, groin, or skin cultures, stratified by the time since the prior CDI diagnosisDisclosures All authors: No reported disclosures.

Interhospital patient transfers between Ontario's academic and large community hospitals increase the risk of Clostridium difficile infection

The objective of this study is to determine the impact of interhospital patient transfers on the risk of Clostridium difficile infection (CDI). The number of interhospital patient transfers and CDI cases for 11 academic and 40 large community hospitals (LCHs) were available from 2010-2015. These data were used to compute a CDI score for each sending facility as a measure of CDI pressure on the receiving facility. This CDI score was included as a variable in a multilevel mixed-effect Poisson regression model of CDI cases. Other covariates included year, CDI testing strategy, antimicrobial stewardship program (ASP), and criteria used for patient isolation. Hospital-specific random effects were estimated for the baseline rate of CDI (intercept) and ASP effect (slope). The CDI score ranged from 0-103, with a mean score ± SD of 20.4 ± 21.8. Every 10-point increase in the CDI score was associated with a 4.5% increase in the incidence of CDI in the receiving academic hospital (95% confidence interval [CI], 0.9-8.5) and 3.6% increase in the receiving LCHs (95% CI, 0.3-7). The random components of the model varied significantly, with a strong negative correlation of -0.85 (95% CI, -0.94 to -0.65). Our results suggest interhospital patient transfers increase the risk of CDI. ASPs appear to reduce this risk; however, these ASP effects demonstrate significant heterogeneity across hospitals.

Comparative epidemiology of Clostridium difficile infection: England and the USA

To examine whether there is an epidemiological difference between Clostridium difficile infection (CDI) inpatient populations in England and the United States. A cross-sectional study. National administrative inpatient discharge data from England (Hospital Episode Statistics) and the USA (National Inpatient Sample) in 2012. De-identifiable non-obstetric inpatient discharges from the national datasets were used to estimate national CDI incidence in the United States and England using ICD9-CM(008.45) and ICD10(A04.7) respectively. The rate of CDI was calculated per 100 000 population using national population estimates. Rate per 100 000 inpatient discharges was also calculated separated by primary and secondary diagnosis of CDI. Age, sex and Elixhauser comorbidities profiles were examined. The USA had a higher rate of CDI compared to England: 115.1/100 000 vs. 19.3/100 000 population (P < 0.001). CDI age profiles differed between the countries (P < 0.001): in England, patients ≥75 years constitute a larger proportion of CDI cases, whilst those aged 25-70 constitute more cases in the US (P < 0.001). Overall adjusted odds of CDI in females compared to males was elevated in both England (odds ratios (OR) 1.26 95% CI [1.21,1.31] P < 0.001) and the USA (OR 1.20 95% CI [1.18,1.22] P < 0.001). The proportion of CDI patients with comorbidities was greater in the USA compared to England apart from dementia, which was greater in England (9.63% vs. 1.25%, P < 0.0001). The 2012 inpatient CDI rate within the USA was much higher than in England. Age and comorbidity profiles also differed between CDI patients in both countries. The reasons for this are likely multi-factorial but may reflect national infection control policy.

Analysis of two Clostridium difficile outbreaks in an acute health care facility

BACKGROUND: Many Clostridium difficile infection (CDI) cases are classified as health care–associated (HA)-CDI using standard definitions. However, this classification may not be accurate and may lead to the declaration of outbreaks when the acquisition of C. difficile is not HA, and the source of infection or strain type are unknown. OBJECTIVE: To characterize C. difficile ribotypes to establish the relationship between CDI cases involved in two outbreaks at a Canadian hospital, and to determine whether there was a common source of infection between the outbreaks. METHODS: C. difficile isolates from infected patients involved in two CDI outbreaks affecting two wards (A and B) were analyzed using ribotyping and mutlilocus sequence typing (MLST) techniques. Antibiotic use and length of hospital stay for the CDI cases during the outbreaks were also analyzed by reviewing patient charts. RESULTS: C. difficile was isolated from 19 of 22 CDI patients. Twelve patients in ward A carried 10 different ribotypes, of which eight were isolated once. Similarly, seven patients in ward B carried five different ribotypes, of which four were isolated once. Only three ribotypes – 027, 056, and 106 – were isolated in both wards, of which at least two isolates of ribotype 027 and ribotype 056 belonged to different MLST groups, indicating genetic diversity, even among the shared ribotypes between the two wards. All CDI patients were isolated throughout their hospital stay. The CDI cases did not show an association with the length of hospital stay. Antibiotic use was also documented before and after the onset of HA-CDI. A common pattern of exposure to multiple antibiotics and proton pump inhibitors was noticed before the onset of CDI that continued afterward. CONCLUSION: Two concurrent CDI outbreaks in two separate wards involving 22 patients admitted to a Canadian acute health care facility in 2012 are reported. On examining these two outbreaks, there was no evidence to support ongoing nosocomial transmission of C. difficile among these patients. The genetic diversity of recovered C. difficile isolates suggested that the outbreaks could not be attributed to a common source or sustained transmission of an outbreak strain.

Clostridium difficile multidisciplinary team root cause analysis: impact on clinical care and circumvention of financial penalties posed by clinical commissioning groups, but at what cost?

In Hampshire Hospitals NHS Foundation Trust, in addition to an on-the-spot investigation into hospital-onset Clostridium difficile infection (CDI) by the infection prevention team, a multidisciplinary team root cause analysis (MDT-RCA) forum has been developed. The MDT-RCA aims to deliver a more thorough investigation into individual cases and the recommendation of cases to the clinical commissioning groups (CCG) appeals panel against potential financial penalties (£10,000 per breached case). We mainly aimed to investigate the financial impact of MDT-RCAs to the Trust. Over two years, 84 cases of hospital-onset CDI cases were reviewed by the MDT-RCA forum. Among this cohort, no additional learning outcomes were identified by the MDT-RCAs over those that were found by on-the-spot investigations. In total, 543 staff members attended the MDT-RCAs at a potential cost to the Trust of £23,795.74-£51,670.10. The Trust appealed against financial penalties for 27 cases and 14 were successful, i.e. £140,000 would have been avoided had targets been breached by 14 cases. However, targets were only breached by two cases, meaning only £20,000 in fines was avoided. Deducting this from the total costs of the MDT-RCA meant the Trust lost £3,795.74-£31,670.10. Over the two years reviewed, the MDT-RCA proved to be costly to the Trust, with no additional learning or quality improvement measures identified.

Epidemiology of Clostridium difficile in infants in Oxfordshire, UK: Risk factors for colonization and carriage, and genetic overlap with regional C. difficile infection strains.

BackgroundApproximately 30–40% of children <1 year of age are Clostridium difficile colonized, and may represent a reservoir for adult C. difficile infections (CDI). Risk factors for colonization with toxigenic versus non-toxigenic C. difficile strains and longitudinal acquisition dynamics in infants remain incompletely characterized.MethodsPredominantly healthy infants (≤2 years) were recruited in Oxfordshire, UK, and provided ≥1 fecal samples. Independent risk factors for toxigenic/non-toxigenic C. difficile colonization and acquisition were identified using multivariable regression. Infant C. difficile isolates were whole-genome sequenced to assay genetic diversity and prevalence of toxin-associated genes, and compared with sequenced strains from Oxfordshire CDI cases.Results338/365 enrolled infants provided 1332 fecal samples, representing 158 C. difficile colonization or carriage episodes (107[68%] toxigenic). Initial colonization was associated with age, and reduced with breastfeeding but increased with pet dogs. Acquisition was associated with older age, Caesarean delivery, and diarrhea. Breastfeeding and pre-existing C. difficile colonization reduced acquisition risk. Overall 13% of CDI C. difficile strains were genetically related to infant strains. 29(18%) infant C. difficile sequences were consistent with recent direct/indirect transmission to/from Oxfordshire CDI cases (≤2 single nucleotide variants [SNVs]); 79(50%) shared a common origin with an Oxfordshire CDI case within the last ~5 years (0–10 SNVs). The hypervirulent, epidemic ST1/ribotype 027 remained notably absent in infants in this large study, as did other lineages such as STs 10/44 (ribotype 015); the most common strain in infants was ST2 (ribotype 020/014)(22%).ConclusionsIn predominantly healthy infants without significant healthcare exposure C. difficile colonization and acquisition reflect environmental exposures, with pet dogs identified as a novel risk factor. Genetic overlap between some infant strains and those isolated from CDI cases suggest common community reservoirs of these C. difficile lineages, contrasting with those lineages found only in CDI cases, and therefore more consistent with healthcare-associated spread.

Faecal lactoferrin and calprotectin in patients with Clostridium difficile infection: a case–control study

Calprotectin and lactoferrin are released by the gastrointestinal tract in response to infection and mucosal inflammation. Our objective was to assess the usefulness of quantifying faecal lactoferrin and calprotectin concentrations in Clostridium difficile infection (CDI) patients with or without free toxins in the stools. We conducted a single-centre 22-month case-control study. Patients with a positive CDI diagnosis were compared to two control groups: group 1=diarrhoeic patients negative for C. difficile and matched (1:1) to CDI cases on the ward location and age, and group 2=diarrhoeic patients colonised with a non-toxigenic strain of C. difficile. Faecal lactoferrin and calprotectin concentrations in faeces were determined for patients with CDI and controls. Of 135 patients with CDI, 87 (64.4%) had a positive stool cytotoxicity assay (free toxin) and 48 (35.6%) had a positive toxigenic culture without detectable toxins in the stools. The median lactoferrin values were 26.8μg/g, 8.0μg/g and 15.8μg/g in CDI patients and groups 1 and 2, respectively. The median calprotectin values were 218.0μg/g, 111.5μg/g and 111.3μg/g, respectively. Among patients with CDI, faecal lactoferrin and calprotectin levels were higher in those with free toxins in their stools (39.2 vs. 10.2μg/g, p=0.003 and 274.0 vs. 166.0μg/g, p=0.051, respectively). Both faecal calprotectin and lactoferrin were higher in patients with CDI, especially in those with detectable toxin in faeces, suggesting a correlation between intestinal inflammation and toxins in stools.

Association between omeprazole use and Clostridium difficile infection among hospitalized patients: A case-control study of the Saudi population.

Background: While few international studies have assessed the association between omeprazole use and the risk of Clostridium difficile infection (CDI), research into this is lacking in Saudi Arabia and the Middle East region. The aim of this study was to determine whether exposure to omeprazole is associated with the risk of Clostridium difficile infection in a sample of hospitalized Saudi patients. Methodology: A retrospective matched case–control study was conducted at the King Abdulaziz Medical City in Riyadh, Saudi Arabia, from 1 August 2010 through 31 July 2015. The analysis included a total of 200 patients: 100 CDI cases and 100 matched controls. Results: The majority (60%, 120 out of 200) of patients had received proton pump inhibitors (PPIs), and a minority (18.5%, 37 out of 200) had received omeprazole. The PPI use was insignificantly higher in CDI cases than in controls. However, the use of omeprazole was significantly higher in CDI cases compared with controls. Specifically, patients receiving omeprazole were two times more likely to develop CDI compared with controls (aOR = 2.1, 95% confidence interval (CI) = (1.007–4.437)). After adjusting for potential predictors of CDI, watery diarrhea (aOR = 59.1, 95% CI = 19.831–175.974) and abdominal pain (aOR = 7.5, 95% CI = 2.184–25.445) were found to be independent predictors of CDI. Conclusions: The data suggests that PPIs were commonly used in patients admitted to King Abdulaziz Medical City in Riyadh: six out of ten patients received PPIs. The findings support a possible association between the use of omeprazole and a high risk of CDI. To confirm causality, the link between omeprazole and CDI should be assessed in a large interventional study.

IMPLICATIONS OF ANTIBIOTHERAPY IN CLOSTRIDIUM DIFFICILE INFECTION TO HOSPITALIZED PATIENTS IN DOLJ COUNTY (ROMANIA)

Objectives. The paper presents the role of the antibiotic treatment and of the favoring factors independent on the antibiotherapy, identified in the occurrence of Clostridium difficile infection (CDI) in hospitalized cases in Dolj County. Material and method. Two groups of patients were analyzed: the CDI AB group (178 cases of CDI that received antibiotic treatment) and the CDI non AB group (36 CDI cases which did not receive antibiotic treatment) recorded between July 2014 and December 2016). Results. The antibiotherapy was a significant risk factor, registered at 83.2% of the cases. The classes of antibiotics associated with the onset of CDI were cephalosporins (73.5% of cases), quinolones (24.2%), penicillins (13.4%), tuberculostatics (6.1%), carbapenems (5.6%). The cases came from the general surgery sections (25.2%), pneumophtiziology (16.8%), intensive care (13.5%), neurology (12.1%), nephrology (6.1%), orthopedics (6.1%), cardiology (4.2%), plastic surgery (4.2%), urology (3.7%). CDI non AB recorded a higher percentage compared to CDI AB in the Intensive care sections (30.6% versus10.1%). The comparative analysis of the characteristics of the patients with CDI AB and CDI non AB did not reveal significant differences linked to the age, sex, interval between admission and onset of the symptoms, recent gastrointestinal surgery or taking antacids. Conclusions. The antibiotherapy is an important risk factor for CDI, cephalosporins and quinolones being frequently-involved. Being admitted to the intensive care unit and the severity of the underlying conditions had a significant role in the appearance of CDI in patients without exposure to antibiotics.

Successful Therapy of Severe Pseudomembranous Colitis Using Combination of Oral Vancomycin and Intracolonic Vancomycin

Clostridium difficile is a major cause of intestinal infection and diarrhoea in individuals following antibiotic treatment. Disease associated with C. difficile infection (CDI) ranges from mild diarrhoea to pseudomembranous colitis (PMC). Severe CDI unresponsive to intravenous (IV) metronidazole therapy requires more aggressive medical management and possible surgical intervention. In the case of ileus, intracolonic and oral vancomycin presented a promising alternative method for administering the antibiotic.We reported a 5 year old boy had non bloody diarrhea with unresponding metronidazol treatment for 10 days.The stool CDI cytotoxin assay was negative.The patient had no antibiotic exposure in the six weeks prior to diarrhoea. Abdominal pain, ileus, fever, leukocytosis were occured (Figure-1). Decompressive fleksible sigmoidoscopy revealed inflamed mucosa and yellow plaque like lesions in sigmoid and descending colon (Figure-2). Stool cultures and analysis for rotavirus, staphylococus, shigella, salmonella and candida were negative. İntraluminal vancomycin (1 gr in 250 ml serum physiologic) was performed during fleksible sigmoidoscopy.Oral vancomycin was started (40 mg/kg)four times a day.The patient's condition improved after treatment and three days later soft diet started (Figure-3). Pediatric CDI cases found 87% reported only diarrhea, 9% had severe CDI and 4% had severe CDI with complications (Toxic megacolon, ileus, intestinal perforation). In the case of ileus, intracolonic and oral vancomycin presented a promising alternative method for administering the antibiotic in clinical suspect of CDI assosiciated PMC. To our knowledge, this is the first documented case to report successful intracolonic and oral vancomycin treatment used in a child patient.Figure: Ileus with excessive colonic dilatation.Figure: Inflamed mucosa and yellow plaque like lesions in fleksible sigmoidoscopy.Figure: Ileus was improved after oral and intracolonic vancomycin treatment.

Impact of the NAP-1 strain on disease severity, mortality, and recurrence of healthcare-associated Clostridium difficile infection

ObjectivesStudies are conflicting regarding the association of the North American pulsed-field gel electrophoresis type 1 (NAP1) strain in Clostridium difficile infection (CDI) and outcomes. We evaluated the association of NAP1 with healthcare-associated CDI disease severity, mortality, and recurrence at our academic medical center. MethodsHealthcare-associated CDI cases were identified from November 1, 2011 through January 31, 2013. Multivariable regression models were used to evaluate the associations of NAP1 with severe disease (based on the Hines VA severity score index), mortality, and recurrence. ResultsAmong 5424 stool specimens submitted to the Clinical Microbiology Laboratory, 292 (5.4%) were positive for C. difficile by polymerase chain reaction (PCR) on or after hospital day 4; 70 (24%) of these specimens also tested positive for NAP1. During the study period, 247 (85%) patients had non-severe disease and 45 (15%) patients had severe disease. Among patients with non-severe disease, 65 (26%) had NAP1 and among patients with severe disease, 5 (11%) had NAP1. After controlling for potential confounders, NAP1 was not associated with an increased likelihood of severe disease (adjusted odds ratio [aOR] = 0.35; 95% confidence interval [CI], 0.13–0.93), in-hospital mortality (aOR = 1.02; 95% CI, 0.53–1.96), or recurrence (aOR = 1.16, 95% CI, 0.36–3.77). ConclusionsThe NAP1 strain did not increase disease severity, mortality, or recurrence in this study, although the incidence of NAP1-positive healthcare associated-CDI was low. The role of strain typing in outcomes and treatment selection in patients with healthcare-associated CDI remains uncertain.

External Validation of Three Prediction Tools for Patients at Risk of a Complicated Course of Clostridium difficile Infection: Disappointing in an Outbreak Setting.

OBJECTIVE Estimating the risk of a complicated course of Clostridium difficile infection (CDI) might help doctors guide treatment. We aimed to validate 3 published prediction models: Hensgens (2014), Na (2015), and Welfare (2011). METHODS The validation cohort comprised 148 patients diagnosed with CDI between May 2013 and March 2014. During this period, 70 endemic cases of CDI occurred as well as 78 cases of CDI related to an outbreak of C. difficile ribotype 027. Model calibration and discrimination were assessed for the 3 prediction rules. RESULTS A complicated course (ie, death, colectomy, or ICU admission due to CDI) was observed in 31 patients (21%), and 23 patients (16%) died within 30 days of CDI diagnosis. The performance of all 3 prediction models was poor when applied to the total validation cohort with an estimated area under the curve (AUC) of 0.68 for the Hensgens model, 0.54 for the Na model, and 0.61 for the Welfare model. For those patients diagnosed with CDI due to non-outbreak strains, the prediction model developed by Hensgens performed the best, with an AUC of 0.78. CONCLUSION All 3 prediction models performed poorly when using our total cohort, which included CDI cases from an outbreak as well as endemic cases. The prediction model of Hensgens performed relatively well for patients diagnosed with CDI due to non-outbreak strains, and this model may be useful in endemic settings. Infect Control Hosp Epidemiol 2017;38:897-905.

Stochastic modelling and inference in electronic hospital databases for the spread of infections: Clostridium difficile transmission in Oxfordshire hospitals 2007-2010.

The combination of genetic information with electronic patient records promises to provide a powerful new resource for understanding human disease and its treatment. Here we develop and apply a novel stochastic compartmental model to a large dataset on Clostridium difficile infection (CDI) in three Oxfordshire hospitals over a 2.5 year period which combines genetic information on 858 confirmed cases of CDI with a database of 750,000 patient records. C. difficile is a major cause of healthcare-associated diarrhoea and is responsible for substantial mortality and morbidity, with relatively little known about its biology or its transmission epidemiology. Bayesian analysis of our model, via Markov chain Monte Carlo, provides new information about the biology of CDI, including genetic heterogeneity in infectiousness across different sequence types, and evidence for ward contamination as a significant mode of transmission, and allows inferences about the contribution of particular individuals, wards, or hospitals to transmission of the bacterium, and assessment of changes in these over time following changes in hospital practice. Our work demonstrates the value of using statistical modelling and computational inference on large-scale hospital patient databases and genetic data.

Incidence and Risk Factors for Community and Hospital Acquisition of Clostridium difficile Infection in the Tel Aviv Sourasky Medical Center.

OBJECTIVES To estimate the incidence and identified risk factors for community-acquired (CA) and hospital-acquired (HA) Clostridium difficile infection (CDI) METHODS We conducted 2 parallel case-control studies at Tel Aviv Sourasky Medical Center from January 1, 2011, to December 31, 2014. We identified persons with CDI, determined whether infection was community or hospital acquired, and calculated incidence rates from 2007 to 2014. We collected demographic, clinical, and epidemiological information for CDI cases and hospitalized control cases and estimated the odds ratio with 95% confidence interval using conditional logistic regression. RESULTS In total, 1,563 CDI cases were identified in the study. The incidence rate of CA-CDI and HA-CDI increased by 1.6-fold and 1.2-fold, respectively, during 2012-2014. However, the incidence rate of CA-CDI was 0.84 per 100,000 (95% CI, 0.52-1.30), the rate for HA-CDI was 4.7 per 10,000 patient days (95% CI, 4.08-5.38), respectively, in 2014. We identified several factors as independent variables significantly associated with HA-CDI: functional disability, presence of nasogastric tube, antibiotic use, chemotherapy, infection by extended-spectrum β-lactamases, and mean of albumin values. Risk factors independently associated with CA-CDI were close contact with a family member who had been hospitalized in the previous 6 months, inflammatory bowel disease, and home density index (adjusted odds ratio, 25.7; 95% confidence interval, 3.99-165.54; P=.001). CONCLUSIONS The identification of the main modifiable risk factors for HA-CDI (antibiotic exposure and hypoalbuminemia) and for CA-CDI (close contact with a family member who had been hospitalized in the previous 6 months) is likely to optimize prevention efforts; these factors are critical in preventing the spread of CDI. Infect Control Hosp Epidemiol 2017;38:912-920.

Evaluation of Infection Prevention of &lt;i&gt;Clostridium difficile&lt;/i&gt; Infection by Potassium Peroxymonosulfate Disinfectant Cleaner

The number of cases of Clostridium difficile infection (CDI) had increased in our hospital since November 2013. As the outbreak of horizontal infection of CDI was strongly suspected, we introduced potassium peroxymonosulfate cleaner (RST) in May 2014. The incidence of CDI was significantly reduced after beginning to use RST (May 2014 - December 2015) compared to the pre-introduction period (January 2012 to April 2014). The results of this study suggest that environmental improvement using RST is a useful approach for suppressing horizontal infection of Clostridium difficile.

Investigating antimicrobial prescribing pattern before the development of CDI using data linkage

ABSTRACTObjectivesPrior use of antimicrobials, in particular broad-spectrum antimicrobials, is associated with the development of Clostridium difficile infection (CDI). Our previous work has demonstrated increased risk with cumulative exposure but there is limited evidence on specific patterns of cumulative antimicrobial prescribing prior to infection. Understanding this pattern will help inform antimicrobial stewardship. This study aims to investigate the prescribing patterns for CDI cases with more than 4 weeks cumulative antimicrobial exposure during the 6 months prior to their CDI date.ApproachWe linked three Scottish patient-level data sets: laboratory confirmed CDI (ECOSS), prescriptions for antimicrobials in primary care (PIS) and all hospital admissions (SMR01). From ECOSS all cases of CDI reported in the period August 2010 to July 2013 were identified. Each CDI case was linked to SMR01 to allocate case type (either hospital or community associated) and to PIS for previous antimicrobial prescriptions. Visual representation of temporal exposure indicating both duration and drug type of each antimicrobial dispensed during the 6 month period before the infection was produced to clearly understand the pattern of prescribing.ResultsIn the study period, there were a total of 1557 community acquired CDI cases without recent (prior 3 months) hospitalisation. Among them, 287 (18%) cases had more than 4 weeks prior cumulative antimicrobial exposure accumulating a total of 1311 dispensed prescriptions. Cases had an average 4 (Q1:3,Q3:6) prescriptions and 2 (Q1:2,Q3:3) different types of antimicrobials dispensed. The timeline plot shows that repeated short duration prescriptions contributed more to cumulative exposure than long duration prophylaxis. The most common antimicrobials prescribed were amoxicillin (38% of cases), trimethoprim (30%) and flucloxacillin (27%). The median duration per prescription for each of these was less than 2 weeks. The antimicrobials that had a median duration of around a month per prescription were oxytetracycline (3%) and clindamycin (6%).&#x0D; ConclusionsThis study of a national linked patient level data set contained sufficient numbers of cases to enable investigation of the prescribing pattern in individuals with highest risk cumulative exposure. This study uses NHS Scotland’s developing Infection Intelligence Platform which will place Scotland as a world leader in the use of health informatics to support infection control and antimicrobial stewardship.

Risk Factors for Hospital-acquired Clostridium difficile Infection Among Pediatric Patients With Cancer.

Hospital-acquired Clostridium difficile infection (CDI) may cause life-threatening colitis for children with cancer, making identification of risk factors important. We described characteristics of pediatric cancer patients with primary and recurring CDI, and evaluated potential risk factors. Among 189 cancer patients, 51 cases (27%) of CDI and 94 matched controls of cancer patients without CDI were analyzed. Multivariable logistic regression was used to evaluate the association between CDI and several potential risk factors. Median age of CDI cases was lower (3.3 y; 0.60 to 16.2) than controls (7.7 y; 0.4 to 20.5). Median duration of neutropenia before CDI was longer for CDI cases (10.0 d; 0.0 to 30.0) compared with duration calculated from reference date in controls (6.0 d; 0.0 to 29.0). Multivariable analysis showed that older age was associated with reduced risk (≥7 vs. 0 to 3 y, odds ratio=0.11; 95% confidence interval, 0.02-0.54), and prolonged neutropenia was associated with increased risk (odds ratio=1.11; 95% confidence interval, 1.01-1.22). CDI recurred in 26% of cases. Younger age and prolonged neutropenia were risk factors for CDI in children with cancer. Increasing awareness to these risk factors will help to identify opportunities for CDI prevention in cancer patients.