Prevalence Of Clostridioides Difficile Infection Research Articles

Impact of COVID-19 pandemic on prevalence of Clostridioides difficile infection in a UK tertiary centre

Serious concerns have been raised about a possible increase in cases of Clostridioides difficile infection (CDI) during the COVID-19 pandemic. We conducted a retrospective observational single centre study which revealed that total combined community and hospital-based quarterly rates of CDI decreased during the pandemic compared to the pre-pandemic period.

Clostridioides difficile Diarrhea: An Emerging Problem in a South Indian Tertiary Care Hospital.

ContextClostridioides difficile infection (CDI) is one of the most common infectious causes of hospital-acquired diarrhea. The actual burden of the disease is underestimated in India due to inadequate diagnostic methods and limited studies conducted. Aims The aim of this study was to determine the burden and risk factors of CDI among patients with hospital-acquired diarrhea. Methods and Materials Stool specimen of patients (age > 1 year) with hospital-acquired diarrhea were screened for glutamate dehydrogenase antigen and toxin using an enzyme immunoassay. If both antigen and toxin were present, it was reported as positive for toxigenic CDI. Samples positive for antigen and negative for toxin were further tested with Cepheid GeneXpert assay for detecting the toxin producing gene. Results Of 75 patients (mean age 36.07 ± 20.79, 64% males), 14 (18.67%) patients were positive for toxigenic Clostridioides difficile ( C. difficile ) and 3 (4%) patients were nontoxigenic C. difficile . Addition of GeneXpert to the testing algorithm increased the yield of toxin detection in 5/14 patients who were negative by toxin assay. On analysis of risk factors, prolonged hospital stay was found to have significant association ( p -value = 0.022). Patients with factors like intensive care unit stay, presence of diabetes mellitus as a comorbidity, and exposure to antibiotics like carbapenems and glycopeptides have been found to have a higher prevalence of CDI. Conclusions The prevalence of CDI in our population was 18.67% and the major risk factor associated was prolonged hospital stay. The addition of GeneXpert for the detection of toxin gene increased the yield from 12 to 18.68%.

Diagnostic deficiencies of C. difficile infection among patients in a tertiary hospital in Saudi Arabia: A laboratory-based case series.

Clostridioides difficile infection (CDI) has become a threatening public health problem in the developed world. In the kingdom of Saudi Arabia, prevalence of CDI is still unknown due to limited surveillance protocols and diagnostic resources. We used a two-step procedure to study and confirm C. difficile cases. We also studied toxin profiles of these isolates.Stool samples were collected from symptomatic patients and clinically suspected of CDI for almost 12 months. Isolates were confirmed by culture method followed by 16S rRNA sequencing. Multiplex PCR was performed for the identification of toxin A, toxin B and binary toxin genes and compared to Gene Expert results.Out of the 47 collected samples, 27 were successfully grown on culture media. 18 samples were confirmed as C. difficile by both culture and 16S rRNA sequencing. Interestingly, the rest of the isolates (9 species) belonged to different genera. Our results showed 95% of samples were positive for both toxin A and B (tcdA, tcdB) and all samples exhibited the toxin gene regulator tcdC. All samples were confirmed negative for the binary toxin gene ctdB and 11% of the isolates were positive for ctdA gene. Interestingly, one isolate harbored the binary toxin gene (cdtA+) and tested negative for both toxins A and B.We believe that combining the standard culture method with molecular techniques can make the detection of C. difficile more accurate.

Clostridioides difficile colonization and infection in a cohort of Australian adults with cystic fibrosis

Little is known about Clostridioides difficile infection (CDI) in patients with cystic fibrosis (CF). The aim of this study was to investigate the prevalence, molecular epidemiology and risk factors for CDI in asymptomatic and symptomatic adults with CF in Western Australia. Faecal samples from symptomatic and asymptomatic patients were prospectively collected and tested for the presence of C.difficile by toxigenic culture. Ribotyping was performed by established protocols. Logistic regression analysis was performed to analyse the risk factors for C.difficile colonization and infection. Extensive environmental sampling was performed within the CF clinic in Perth. The prevalence rates of asymptomatic toxigenic and non-toxigenic C.difficile colonization were 30% (14/46 patients) and 24% (11/46 patients), respectively. Fifteen ribotypes (RTs) of C.difficile were identified, of which non-toxigenic RT 039 was the most common. Among the symptomatic patients, the prevalence of toxigenic CDI was 33% (11/33 patients). Impaired glucose tolerance/diabetes mellitus and duration of intravenous antibiotic use in the past 12 months were significantly associated with increased risk of asymptomatic toxigenic C.difficile carriage and CDI. A trend towards higher CF transmembrane conductance regulator modulator treatment was observed in the CDI group. Extensive environmental sampling showed no evidence of toxigenic C.difficile contamination within the CF clinic. A high prevalence of asymptomatic carriage of toxigenic C.difficile was observed in adults with CF, comparable with that observed in the symptomatic CF population. There was no evidence of direct person-to-person transmission.

Laboratory Diagnostic Methods for Clostridioides difficile Infection: the First Systematic Review and Meta-analysis in Korea.

BackgroundVarious methods are used for the diagnosis of Clostridioides difficile infection (CDI). We systematically analyzed and investigated the performance of current laboratory diagnostic methods for CDI.MethodsWe performed systematic review and meta-analysis of studies in PubMed, Web of Science, Cochrane Library, and KoreaMed. The following methods were evaluated glutamate dehydrogenase (GDH) enzyme immunoassays (GDH EIAs), toxin A and B detection by enzyme immunoassays (toxin AB EIAs), and nucleic acid amplification tests (NAATs) for C. difficile toxin genes. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each method were calculated.ResultsBased on 39 studies, the pooled sensitivities/specificities were 92.7%/94.6%, 57.9%/97.0%, and 90.0%/95.8% for GDH EIAs, toxin AB EIAs, and NAATs, respectively, compared with those of toxigenic culture. The pooled sensitivities of automated EIAs were significantly higher than those of non-automated EIAs for both GDH and toxins A and B. The pooled sensitivity of Xpert C. difficile was significantly higher than those of other NAATs. PPVs increased as CDI prevalence increased, and NPVs were excellent when CDI prevalence was low; at CDI prevalence of 5%, PPV = 37%-65% and NPV = 97%-100%; at CDI prevalence of 50%, PPV = 92%-97% and NPV = 65%-98%.ConclusionsToxin AB EIAs still show unsatisfactory sensitivity, whereas GDH EIAs and NAATs show relatively high sensitivity. However, toxin AB EIAs are the most specific tests. This study may provide useful information for CDI diagnosis.

Clostridioides difficile Infection in Chronic Kidney Disease-An Overview for Clinicians.

Increased incidence of Clostridioides difficile infection (CDI), occurrence of severe and complicated CDI, and more frequent occurrence of drug-resistant, recurrent or non-hospital CDI has become a worldwide clinical problem. CDI is more common in patients with chronic kidney disease (CKD) than in the general population. CDI seems to be associated with frequent hospitalization, frequently used antibiotic therapy, dysbiosis, and abnormalities of the immune system observed in CKD patients. Dysbiosis is a common disorder found in CKD patients. It may be related to insufficient fiber content in the diet, reduced amount of consumed fluids and often reduced physical activity, constipation, impaired gastrointestinal motility, multidrug pharmacotherapy, and uremic milieu in CKD stage 5. In patients with CKD the clinical manifestations of CDI are similar to the general population; however, more frequent recurrence of CDI and higher prevalence of severe CDI are reported. Moreover, the increase in CDI related mortality is observed more in CKD patients than in the general population. The aim of this review paper is to summarize the current knowledge concerning the epidemiology, pathogenesis, clinical picture, and prevention and treatment in CKD patients.

S0164 Clostridioides difficile Infection in COVID-19 Patients

INTRODUCTION: Gastrointestinal manifestations including diarrhea are prevalent among COVID-19 patients. Given the frequent use of broad-spectrum antibiotics, COVID-19 patients are also at substantial risk for hospital-acquired diarrheal illnesses. We aimed to evaluate the prevalence and outcomes of Clostridioides difficile infection (CDI) among hospitalized patients with COVID-19. METHODS: This was a retrospective cohort study of patients hospitalized with laboratory confirmed COVID-19 across 9 hospitals in Massachusetts in 3/11/2020–4/2/2020. All patients underwent stool testing for CDI with glutamate dehydrogenase (GDH) and ELISA immunoassay (EIA) for toxin. Inconclusive GDH/EIA with high clinical suspicion were confirmed with polymerase chain reaction (PCR). Positive CDI rate in COVID-19 patients was compared with local historical inpatient CDI testing data from 2019. Outcomes and mortality were also compared amongst COVID-19 patients with and without CDI. RESULTS: Of the 390 hospitalized patients with COVID-19, 97 (24.9%) were tested for CDI and included in the study. All patients received ≥2 antibiotics (median = 4, IQR 2–5.5). Compared to historical controls, COVID-19 patients did not have higher overall CDI positive rate (5.2% [n = 5] vs 9.8% [n = 280]; P = 0.16). Specifically, GDH/EIA positive rates were similar between both groups (5.2% vs 5.3%). There were no statistically significant differences in median antibiotic use, PPI use, laboratory data or need for ICU care between CDI vs non-CDI patients. However, all-cause mortality was significantly higher among CDI patients (80% vs 12.2%; P < 0.0001) Table 1. CONCLUSION: The prevalence of CDI was not higher among COVID-19 patients despite widespread use of broad-spectrum antibiotics. With strict isolation of COVID-19 patients in most hospitals, together with aggressive hand washing and donning/doffing protocols, it is possible that such rigorous measures resulted in the unintended benefit of reducing nosocomial CDI. However, albeit a limited sample size, development of CDI was associated with significantly worse outcomes and higher mortality. As such, early CDI testing should be implemented among patients with COVID-19 to ensure prompt diagnosis and management.Table 1.: (A) Clostridioides difficile infection stool testing of COVID-19 patients compared to all inpatient CDI tests in 2019. (B) Hospitalization course and outcomes of COVID-19 patients with and without CDI. * Stool PCR only performed with GDH/EIA indeterminant samples

S3188 Risk of Acquiring Clostridiodes difficile Infection in IBD Patients With Anemia

INTRODUCTION: The prevalence of anemia in inflammatory bowel disease (lBD) ranges from 6% to 74% and about 25% may develop moderate to severe anemia. It is not uncommon to treat anemia in IBD patients with red blood cell (RBC) transfusions. Previously it was shown that IBD with anemia is associated with a prolonged hospital stay, higher morbidity, and mortality rates. Prolonged length of stay by itself increases the risk of hospital-acquired infections including Clostridioides difficile infection (CDI). In addition, allogeneic RBC transfusions are associated with infections due to the risk of contamination and immunomodulation caused in the recipients due to the antigenic challenge. Not many studies were published on the association of CDI with RBC transfusions in IBD. Our objective is to assess the risk of acquiring CDI in anemic IBD patients treated with RBC transfusions. METHODS: We performed a population-based study using IBM EXPLORYS, a HIPPA-enabled platform that includes over 65 million patient data from multiple hospitals. A cohort of anemic IBD patients was identified and stratified into 2 groups i.e. who received and who did not receive RBC transfusions. CDI prevalence was calculated and demographic characteristics, exposure to antibiotics, and immunosuppressive treatment were compared. Chi-square with a significant P-value set at 0.05 was used for comparison between the groups. RESULTS: Of the total 319,400 IBD patients, 105,290 had anemia (33%) and 18,170 with anemia received RBC transfusions (17%). CDI prevalence in patients who received RBC transfusions was significantly higher than those who did not (19% vs. 7%, P < .00001).Furthermore, CDI prevalence in patients who received more than 2 RBC units (1900/8660, 22%) was significantly higher than those who received ≤2 units (1570/ 9510, 16.5%) (P < .00001). Significant differences in some demographic characteristics and higher recent antibiotic exposure in the group with no RBC transfusions were noted (Table). CONCLUSION: IBD patients with anemia, treated with RBC transfusions are more likely to develop CDI compared to those who did not receive any RBC transfusions. The risk of CDI is higher with more of RBC units. Restrictive transfusion strategies may decrease the risk ofacquiring CDI.Table 1.: Characteristics of IBD Patients with Anemia who Developed CDI with and without following RBC transfusions.

Outcomes of Fecal Microbiota Transplantation in Patients With Inflammatory Bowel Diseases and Recurrent Clostridioides difficile Infection

Outcomes of Fecal Microbiota Transplantation in Patients With Inflammatory Bowel Diseases and Recurrent Clostridioides difficile Infection

Clostridium difficile Infection: An Epidemiology Update.

Clostridium (reclassified as " Clostridioides ") difficile infection (CDI) is a healthcare-associated infection and significant source of potentially preventable morbidity, recurrence, and death, particularly among hospitalized older adults. Additional risk factors include antibiotic use and severe underlying illness. The increasing prevalence of community-associated CDI is gaining recognition as a novel source of morbidity in previously healthy patients. Even after recovery from initial infection, patients remain at risk for recurrence or reinfection with a new strain. Some pharmaco-epidemiologic studies have suggested an increased risk associated with proton pump inhibitors and protective effect from statins, but these findings have not been uniformly reproduced in all studies. Certain ribotypes of C. difficile , including the BI/NAP1/027, 106, and 018, are associated with increased antibiotic resistance and potential for higher morbidity and mortality. CDI remains a high-morbidity healthcare-associated infection, and better understanding of ribotypes and medication risk factors could help to target treatment, particularly for patients with high recurrence risk.

Clostridioides difficile ribotypes 001 and 126 were predominant in Tehran healthcare settings from 2004 to 2018: a 14-year-long cross-sectional study

ABSTRACT Clostridioides difficile infection (CDI) remains a major healthcare problem worldwide, however, little is known about CDI epidemiology in Iran. Between December 2004 and November 2018, 3649 stool samples were collected from patients in 69 hospitals and medical centres in Tehran and were cultured for the presence of C. difficile; isolates were characterized by PCR ribotyping and toxin genes detection. A total of 582 C. difficile isolates were obtained and the overall CDI prevalence was 15.9%; 290 (49.8%) cases were healthcare-associated (HA) and 292 (50.2%) cases were community-associated (CA). Of these, DNA of 513 isolates submitted for ribotyping. The ribotype and/or WEBRIBO type could be assessed in 366 (62.9%) isolates. The most frequent RTs were 001 (n = 75, 12.9%), 126 (n = 65, 11.2%) and 084 (n = 19, 3.3%); the toxin gene profile tcdA + B + /cdtA + B + (n = 112, 19.2%) was the most common. Fifteen C. difficile isolates (2.6%) did not carry any toxin genes. There was no difference between frequently found RTs in HA-CDI and CA-CDI, except for RT 029 which was more likely to be associated with healthcare origin (12/15, p-value = 0.02). No isolate of RTs 027 or 078 was identified. Importantly, RTs 031, 038, 039, 084, 085 reported previously as RTs with an absence of toxin genes, revealed the presence of toxin genes in our study. Using Simpson’s reciprocal index of diversity, we found that RT diversity decreased as the prevalence of the RT 084 increased (R = −0.78, p-value = 0.041). Different patterns in CDI epidemiology underscore the importance of local surveillance and infection control measures in Tehran healthcare settings.

747 Pilot Study of Gut Dysbiosis and Bile Acid Dysmetabolism in Active Ulcerative Colitis

INTRODUCTION: Ulcerative colitis (UC) is a chronic relapsing inflammatory disease of the colon associated with an increased risk for Clostridioides difficile infection (CDI). C. difficile is a spore-forming organism that colonizes the GI tract and is potentially pathogenic. Under healthy conditions, homeostasis of the gut microbiome plays a role in preventing germination of C. difficile spores while bile acids are vital to the germination process. Primary bile acids can stimulate germination of C. difficile spores while secondary bile acids inhibit growth of the vegetative form. The aim of this study is to assess for changes in the gut microbiome and bile acid profile with active UC as compared to remission that may explain the increased CDI risk. METHODS: After obtaining IRB approval, we performed a single center, prospective, cohort study of Veteran's with active UC at the McGuire VA Medical Center. After obtaining consent, subjects with active UC, based on markers of inflammation and elevated Simple Clinical Colitis Activity Index score (≥5), provided a stool sample for analysis of the gut microbiome (using fingerprinting of the 16S rRNA), bile acid profile (using high performance liquid chromatography) and for the presence of Clostridioides species (using 7α-dehydroxylating bacteria analysis). Subjects were treated for their active UC and a second stool sample was collected in the setting of clinical remission for repeat analyses. RESULTS: Four males with active UC enrolled, median age 61 yrs, however subject 2 was excluded due to suboptimal sample size. The total bile acids were relatively unchanged in both samples however there were less secondary bile acids (deoxycholic acid and lithocholic acid) in the remission samples in 2 of 3 subjects (Table 1). With active UC, study subjects had a higher concentration of C. scindens (Figure 1). Inversely, subjects had higher concentrations of the C. difficile toxin B gene during clinical remission (Figure 2). The results of the microbiome analysis are pending. CONCLUSION: In this limited pilot study, we found that patients with UC have a decreased luminal concentration of both total and secondary bile acids compared to healthy controls. Active UC seems to lead to a decrease in secondary bile acids, including C. scindens, with a subsequent increase in the presence of C. difficile toxin. This change in bile acid profile could be contributing to the increased prevalence of CDI in IBD patients.

Cannabis use and risk of Clostridioides difficile infection: Analysis of 59,824 hospitalizations

BackgroundThe prevalence of Clostridioides difficile Infection (CDI), the most notorious hospital acquired disease, and of excessive cannabis use (cannabis use disorder (CUD)) have both been steadily rising. Although cannabidiol, an active ingredient of cannabis, maintains gut integrity and suppresses entero-toxins from Clostridioides difficile, the relationship between CUD and CDI has not been studied. MethodsWe selected adult records (age ≥ 18 years) from the Nationwide Inpatient Sample 2014, and identified CUD and other clinical conditions using ICD-9-CM codes. We used propensity scores derived from a multivariate logistic model to match CUD to non-CUD in a 1:1 ratio (29,912:29,912). We estimated the relative risk for CDI using log-binomial regression models with generalized estimating equations [SAS 9.4]. ResultsAmong the matched hospitalizations (n = 59,824), cannabis usage was associated with a reduced prevalence of CDI (prevalence: 455.5 [95% CI: 385.1–538.8] vs. 636.4 [95% CI: 549.9–736.5] per 100,000 hospitalizations), resulting in a 28% reduced risk of CDI (relative risk: 0.72 [95% CI: 0.58–0.88]; p = 0002). Non-dependent and dependent CUD respectively had 23% and 80% reduced likelihood of CDI when compared to non-cannabis users (0.77 [95% CI: 0.60–0.95] and 0.20 [95% CI: 0.06–0.54]; p < 0.05). Furthermore, dependent users had less risk of CDI compared to non-dependent users (0.26 [95% CI: 0.08–0.88]; p = 0.01). ConclusionsCUD was associated with a decreased risk of CDI amongst hospitalized patients. Prospective and molecular mechanistic studies are required to elucidate how cannabis and its contents impacts CDI.

The rise of Clostridioides difficile infections and fall of associated mortality in hospitalized advanced cirrhotics.

Cirrhotics are at increased risk of Clostridioides difficile infection (CDI) and its associated high morbidity and mortality. However, the impact of CDI in cirrhotics over time remains unclear. This study analyses prevalence and mortality in CDI in hospitalized patients with advanced cirrhosis over 15years and identifies trends. Using the Nationwide Inpatient Sample (NIS) from 1998 to 2014, 3049696 weighted patients with advanced cirrhosis (defined as evidence of decompensation or oesophageal varices) were identified using a validated algorithm of ICD-9-CM codes and included in the study. Trends were analysed using Cochran Armitage test and joinpoint regression and compared to the general population. Multivariable logistic regression was performed controlling for risk factors that affect mortality in cirrhotics. CDI prevalence in advanced cirrhotics increased from 0.8% to 2.6%, annual percent change (APC) 8.8% (compared to 7.6% for the general population), while CDI-related mortality decreased from 20.7% to 11.3%, APC -3.4% (compared to -2.0% for the general population), from 1998 to 2014. CDI independently increased mortality in advanced cirrhotics (OR 1.47, P<0.001) and was associated with acute kidney injury (AKI) (OR 2.09, P<0.001), which itself significantly increased mortality (OR 4.54, P<0.001). Hepatic encephalopathy and Hispanic ethnicity were interestingly associated with a lower prevalence of CDI. CDI is increasingly common in advanced cirrhotics, but on the contrary, its associated mortality is decreasing. Despite improvements in outcomes in patients with advanced cirrhosis, CDI is associated with an increased mortality, driven by AKI, and therefore, requires aggressive identification and therapy.

471. Prevalence and Characteristics of Clostridioides difficile Infection in Bangladesh

BackgroundThe estimated prevalence of Clostridioides difficile infection (CDI) in several South Asian countries is 10.5%, similar to that in North America and Europe. However, the epidemiology of CDI in Bangladesh is unknown. We aimed to assess the prevalence of CDI and assess hospital environmental contamination of toxigenic C. difficile in Bangladesh.MethodsThis was a prospective observational cohort study at two large tertiary care centers in Dhaka, Bangladesh, conducted from January 2017 to December 2017. Stool samples were collected from hospitalized adults with diarrhea (≥3 loose stools in a 24-hour period) and antimicrobial exposure within the past 30 days. Hospital environmental samples were collected by swabbing surfaces of common areas in the hospital. All samples underwent toxigenic culture. C. difficile isolates were tested for toxins A and B and PCR-ribotyped.ResultsOf 204 stool samples collected, 16 (7.8%) were positive for toxigenic C. difficile. Patients with CDI shared a room with significantly more patients (Table 1). Of 392 environmental samples, 48 (12.2%) were positive for toxigenic C. difficile, which was more common in patient care vs. nonpatient care areas (14.4% vs. 7.8%, P = 0.057). Twelve clinical stool isolates and 42 environmental isolates were ribotyped. Ribotypes identified in stool isolates were F017 (50%), FP053-163 (17%), FP435 (17%), F106 (8%), and F014-020 (8%). With the exception of FP435, these were also the most common ribotypes in environmental isolates: F017 (24%), FP053-163 (12%), F106 (26%), and F014-020 (10%).ConclusionFor the first time, we report the prevalence of CDI and ribotypes in at risk patients in Bangladesh. Rates and ribotypes are similar to other resource-rich or resource-limited countries.Table 1: Demographic Data for All Stool SamplesVariableNo toxigenic C. difficile (n = 188)Toxigenic C. difficile (n = 16) P Female sex, n (%)77 (41)9 (56)0.234Age, years, median (IQR)46 (32–58)39 (25–53)0.212Hospital A, n (%)149 (79)13 (81)>0.99Length of prior hospital stay, days, median (IQR)13 (7–23)14 (8–32)0.798Duration of previous antibiotics, days, median (IQR)10 (7–17)12 (6–20)0.687Number of patients in the same room, median (IQR)13 (7–19)19 (14–20)0.009Disclosures K. W. Garey, Merck & Co.: Grant Investigator, Grant recipient.

National Surveillance for Clostridioides difficile Infection, Sweden, 2009-2016.

We report results from a national surveillance program for Clostridioides difficile infection (CDI) in Sweden, where CDI incidence decreased by 22% and the proportion of multidrug-resistant isolates decreased by 80% during 2012-2016. Variation in incidence between counties also diminished during this period, which might be attributable to implementation of nucleic acid amplification testing as the primary diagnostic tool for most laboratories. In contrast to other studies, our study did not indicate increased CDI incidence attributable the introduction of nucleic acid amplification testing. Our results also suggest that successful implementation of hygiene measures is the major cause of the observed incidence decrease. Despite substantial reductions in CDI incidence and prevalence of multidrug-resistant isolates, Sweden still has one of the highest CDI incidence levels in Europe. This finding is unexpected and warrants further investigation, given that Sweden has among the lowest levels of antimicrobial drug use.