Clostridium Difficile Rates Research Articles

Predicting Recurrence of

During the past decade, rates of Clostridium difficile–related pseudomembranous colitis have climbed rapidly, and emergence of a hypervirulent strain

Accounting for regression‐to‐the‐mean in tests for recent changes in institutional performance: Analysis and power

Recent changes in individual units are often of interest when monitoring and assessing the performance of healthcare providers. We consider three high profile examples: (a) annual teenage pregnancy rates in English local authorities, (b) quarterly rates of the hospital-acquired infection Clostridium difficile in National Health Service (NHS) Trusts and (c) annual mortality rates following heart surgery in New York State hospitals. Increasingly, government targets call for continual improvements, in each individual provider as well as overall.Owing to the well-known statistical phenomenon of regression-to-the-mean, observed changes between just two measurements are potentially misleading. This problem has received much attention in other areas, but there is a need for guidelines within performance monitoring.In this paper we show theoretically and with worked examples that a simple random effects predictive distribution can be used to 'correct' for the potentially undesirable consequences of regression-to-the-mean on a test for individual change. We discuss connections to the literature in other fields, and build upon this, in particular by examining the effect of the correction on the power to detect genuine changes. It is demonstrated that a gain in average power can be expected, but that this gain is only very slight if the providers are very different from one another, for example due to poor risk adjustment. Further, the power of the corrected test depends on the provider's baseline rate and, although large gains can be expected for some providers, this is at the cost of some power to detect real changes in others.

A team approach to reducing Clostridium difficile and MRSA bacteraemias

The infection control and prevention team at East Kent Hospitals NHS Trust decreased the number of healthcare-associated infections considerably following the introduction of a range of methods and interventions. The hospital saw a 49% reduction in cases, with no cases of bacteraemias found in January 2008. Clostridium difficile rates per 1,000 bed days between April 2007 and January 2008 were 0.82 per 1,000 bed days – one of the lowest rates in the NHS. The introduction of root cause analysis in 2007 for all C. difficile cases assisted in the decline in infection numbers.

Establishing an infection control accreditation programme to control infection

Faced with increasing scrutiny from the Healthcare Commission, the Department of Health and the Strategic Health Authority, as well as a challenging Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemias reduction target, the infection prevention and control team (IPCT) developed an accreditation programme designed to devolve ownership of infection prevention and control to clinical areas. The programme was devised as a quality improvement programme to improve patient care and has helped to ensure that evidence-based practice is embedded in everyday clinical activities within all clinical areas. The roll out of the programme started in high risk, medium risk and then low risk areas in the hospital and has contributed to significantly improved compliance with infection control policies, procedures and guidelines and a reduction in the MRSA bacteraemia rate by 39% in 2007/2008. Hospital acquired MRSA infections (detected from first isolates) also reduced by approximately 60% in 2007/2008. However, Clostridium difficile rates in 2007/2008 remained comparable with the previous year until early 2008, although a significant reduction is now evident.

Clostridium difficile colitis in cystic fibrosis patients with and without lung transplantation

Despite a large carriage rate of Clostridium difficile among cystic fibrosis (CF) patients, C. difficile-associated disease (CDAD) is rather rare. In case of lung transplantation, the incidence and clinical aspects of CDAD in this patient population are not well known. We reviewed the medical files of all CF patients who presented with symptomatic C. difficile infection from January 1998 to December 2004 and compared the incidence, clinical aspects, severity of disease, and clinical outcome between non-transplanted and transplanted CF patients. Between 1998 and 2004, 106 adult CF patients were followed at our clinic. Forty-nine patients underwent lung transplantation; 15 before 1998 and 34 after 1998. The incidence density of CDAD was higher in transplanted CF patients as compared with non-transplanted CF patients (24.2 vs. 9.5 episodes/100,000 patient-days; risk ratio: 2.93 [1.41-6.08]; P=0.0044). Diarrhea was a very frequent feature, but was notably absent in 20% of the cases. Rates of moderate and severe colitis were similar in both groups. However, only transplanted patients developed complicated colitis. CT scan and endoscopy were performed more frequently in the transplant group. Two transplant recipients died because of CDAD. CF patients who undergo lung transplantation are at a higher risk of developing CDAD and seem to present more often atypical and/or complicated disease. CDAD should be part of the differential diagnosis in case of digestive symptoms, even in the absence of diarrhea, and requires early treatment.

A National Survey of the Prevalence and Impact of Clostridium difficile Infection Among Hospitalized Inflammatory Bowel Disease Patients

We sought to determine nationwide, population-based trends in rates of Clostridium difficile (C. difficile) infection among hospitalized inflammatory bowel disease (IBD) patients in the United States, and to determine its mortality and economic impact. We analyzed discharge records from the Nationwide Inpatient Sample, and used the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify Crohn's disease (CD) and ulcerative colitis (UC) cases, and cases of C. difficile infection between 1998 and 2004. Temporal patterns of C. difficile incidence in IBD patients were compared to non-IBD gastroenterology patients and all-hospitalized patients. The impact of C. difficile on in-hospital mortality and resource utilization was quantified using multiple regression analysis. The prevalence of C. difficile among UC patients (37.3 per 1,000, 95% confidence interval [CI] 34.0-40.7 per 1,000) was higher than that among CD patients (10.9 per 1,000, 95% CI 9.9-12.0 per 1,000), non-IBD gastrointestinal (GI) patients (4.8 per 1,000, 95% CI 4.6-5.0 per 1,000), and general medical patients (4.5 per 1,000, 95% CI 4.2-4.7 per 1,000). C. difficile incidence nearly doubled among UC patients (26.6 per 1,000 to 51.2 per 1,000) over 7 yr. After adjustment for confounders, C. difficile infection was associated with greater mortality among patients with UC (odds ratio [OR] 3.79, 95% CI 2.84-5.06), but not CD (OR 1.66, 95% CI 0.75-3.66). C. difficile was also associated with 65% and 46% longer lengths of stay, which correlated with 63% and 46% higher average hospital charges, for CD and UC patients, respectively. C. difficile infection is a growing public health issue among hospitalized IBD patients, especially those with UC, and is associated with higher mortality and resource utilization, prompting the need for better preventative measures and early detection.

A four year review of Clostridium difficile rates in critical care: Antibiotic control works

A four year review of Clostridium difficile rates in critical care: Antibiotic control works

The Effect of Levofloxacin Prophylaxis on Epidemiology and Microbial Resistance Profiles of Sterile Site Infections in Acute Leukemia Patients.

Background: Neutropenia is the most common predisposing factor that increases the susceptibility of cancer patients (pts) to infection. The use of fluoroquinolones (FQs) as prophylaxis during chemotherapy-induced neutropenia has been shown to decrease the frequency of gram-negative (GN) infections (Cullen et al. NEJM 2005) with the benefit of reduced infection-related mortality in neutropenic pts with cancer (Bucaneve et al. NEJM 2005) and was instituted as part of our institution-wide standard clinical practice in January 2006. The widespread use of FQs for prophylaxis of pts with neutropenia and hematologic malignancies raises concerns about the evolving resistance of organisms.Methods: This retrospective observational study compared acute myeloid leukemia (AML) and acute lymphoid leukemia (ALL) pts, ages 18 and older who were admitted to the hematology service and received levofloxacin prophylaxis (LEVP) within 60 days of admission with those who were admitted but did not receive LEVP during the period of chemotherapy-induced neutropenia. Pts had to have a positive sterile site culture up to 96 hours prior to admission excluding Staphylococcus coagulase negative, Propionibacterium, Corynebacterium, and other common colonizing organisms. Analysis also compared the rates of Methicillin-resistant Staphylococcus aureus (MRSA) infections, positive Vancomycin-resistant Enterococci (VRE) swabs, and positive Clostridium difficile cultures and evaluated them for a correlation LEVP.Results: A total of 213 pts were evaluated between September 2004 and May 2007. Ninety-four pts received LEVP and 119 did not. Patient characteristics were similar between groups. There was a shift from almost equal incidence of gram-positive (GP) and GN cultures in the group without prophylaxis (51% vs 49%, respectively) to a predominance of GP cultures with LEVP (68% vs 32%, respectively). There was a significant decrease in the number of sterile site cultures of GN organisms (n = 94 vs 37, respectively), while cultures of GP organisms remained similar (n = 98 vs. 77, respectively). GN organisms in sterile site cultures occurred less often in the LEVP group, however; the incidence of resistance to levofloxacin in GN was higher (32% vs 15%), particularly the susceptibility profiles of Pseudomonas sp., Escherichia coli, and Stenotrophomonas maltophilia. Both groups had equal cultures of Staphylococcus aureus, but the group receiving LEVP had a greater incidence of MRSA (55% vs 30%). Rates of positive VRE swabs declined and had no apparent correlation with the use of levofloxacin as prophylaxis. There were more documented positive Clostridium difficile cultures in the pts receiving LEVP (29% vs 22%, respectively), but rates of Clostridium difficile have shown a constant increase throughout the institution; therefore, LEVP should not be considered the sole contributing factor to an increased rate of positive cultures.Conclusions: The epidemiology and microbial susceptibility profile of positive sterile site cultures of acute leukemia pts receiving LEVP during chemotherapy-induced neutropenia differed from those that did not. The LEVP group had a decrease in the absolute number of sterile site cultures, number and percent of GN sterile site cultures. There was an increase in GN organism resistance to levofloxacin and the incidence of several GP organisms increased with the number of GP organisms remaining constant.

Treatment Recommendations for Clostridium difficile, Treatment Failures, and Impact on Active Diarrheal Days

ISSUE: Much like many health care facilities, the VANJHCS had experienced an increase in the incidence rate of Clostridium difficile associated diarrhea (CDAD). We had gone from an average of 3 cases per month in previous years to as high as >10 cases for one month. Current recommendations to control the spread of CDAD include contact isolation, environmental cleaning, and stopping antibiotics. Oral metronidazole for 14 days is the drug of choice for initial CDAD episode. Oral vancomycin is an option for patients who cannot take or fail treatment with metronidazole. However in a number of the patients it had been noted that they were failing these recommended antibiotic treatments, thus the adequacy of the 14 days treatment regimen was questioned. The treatment failures also are challenging for Infection Control Professionals because this prolongs the need for contact isolation and hospital stay thus increasing hospital cost.

Clostridium difficilein Discharged Inpatients, Germany

To the Editor: Using discharge diagnoses from US hospitals in 2000–2003, McDonald et al. recently documented a dramatic increase in the rate of Clostridium difficile–associated disease (CDAD) (1). During the same period, a new strain of C. difficile was identified; this strain appears more virulent, at least in part because it produces higher levels of toxin (2). To our knowledge, this strain has not been identified in Germany. However, to address this emerging threat, we conducted a similar analysis of discharge data to compare findings from the United States with data from Germany. We therefore determined the absolute number of inpatient discharges from all hospitals in Germany with the number of discharge diagnoses of CDAD reported in the national Statistische Bundesamt for the years 2000–2004. We then calculated the incidence of CDAD as a discharge diagnosis for each year and stratified our results by age groups (Figure). Figure Incidence of Clostridium difficile–associated disease per 100,000 inpatients upon discharge from hospitals in Germany. Our results confirm the observations from the United States. The effect of C. difficile on illness of patients in hospitals in Germany has escalated dramatically. This is true especially for patients >60 years of age. This trend indicates the need for increased awareness of this pathogen and a concerted effort to control CDAD by reducing unnecessary antimicrobial drug use and implementing currently recommended infection control measures. It also highlights the need to develop more rapid and accurate diagnostic tools and more effective prevention and treatment strategies.

Do PPIs Increase Risk for Community-Acquired

Rates of Clostridium difficile–associated disease (CDAD) are rising sharply, with an increasing number of cases in patients lacking the usual risk

Multihospital surveillance of nosocomial methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, and Clostridium difficile: Analysis of a 4-year data-sharing project, 1999-2002

This study sought to establish a benchmark of resistant organism rates among a cohort of regional hospitals. The Centers for Disease Control and Prevention (CDC) definitions were used to standardize the methodology for obtaining rates per 1000 patient days of nosocomial infection and colonization with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), and nosocomial infection with Clostridium difficile (CDIF). Only newly acquired nosocomial cases were counted. Data were reported as individual hospital control charts and as cohorted aggregate data. VHA East Coast Infection Control Professionals from 32 hospitals in New Jersey and Pennsylvania were involved. Benchmarks were established with pooled mean rates for each cohort. During the observational period, a statistically significant downward trend was observed for VRE and MRSA (P = .02 and .0007, respectively), and an upward trend was observed for CDIF (P = .0256). Benchmarks were established to compare nosocomial MRSA, VRE, and CDIF rates. Although significant changes in rates were observed, no attempt was made to establish a causal relationship between infection control practices and observed rates. However, a secondary gain was achieved through sharing best practices.

Antimicrobial Stewardship

Antimicrobial stewardship is a key component of a multifaceted approach to preventing emergence of antimicrobial resistance. Good antimicrobial stewardship involves selecting an appropriate drug and optimizing its dose and duration to cure an infection while minimizing toxicity and conditions for selection of resistant bacterial strains. Studies conducted over the years indicate that antibiotic use is unnecessary or inappropriate in as many as 50% of cases in the United States, and this creates unnecessary pressure for the selection of resistant species. Because the pharmaceutical industry pipeline for new antibiotics has been curtailed in recent years, and it may be ≥10 years before important new antibiotics to treat certain resistant bacteria find their way to market, a premium has been set on maintaining the effectiveness of currently available agents. Several strategies, including prescriber education, formulary restriction, prior approval, streamlining, antibiotic cycling, and computer-assisted programs have been proposed to improve antibiotic use. Although rigorous clinical data in support of these strategies are lacking, the most effective means of improving antimicrobial stewardship will most likely involve a comprehensive program that incorporates multiple strategies and collaboration among various specialties within a given healthcare institution. Computer-assisted software programs may be especially useful in implementing these comprehensive programs. The antimicrobial stewardship program at the Hospital of the University of Pennsylvania, which has been shown to improve appropriateness of antibiotic use and cure rates, decrease failure rates, and reduce healthcare-related costs, is used as an example in support of this multifaceted, multidisciplinary approach. At this time, data from well-controlled studies examining the effect of antibacterial stewardship on emergence of resistance are limited, but available data suggest that good antibiotic stewardship reduces rates of Clostridium difficile–associated diarrhea, resistant gram-negative bacilli, and vancomycin-resistant enterococci.

An Explosion of C. difficile–Associated Disease

During the past year, many reports described sharply rising rates of Clostridium difficile –associated disease (CDAD), as well as cases of unusually severe CDAD and cases in patients not usually thought to be at risk for infection. An analysis of discharge code data from a sample of U.S. acute-care hospitals found that rates of CDAD more than doubled from 2000 to 2003, with the greatest increase in patients …

Novel Evidence Suggesting Clostridium difficile Is Present in Human Gut Microbiota More Frequently than Previously Suspected

Prevalence rate of Clostridium difficile in healthy human adults is believed to be very low. Our RT-PCR system using glass powder, which can eliminate PCR inhibitors, detected C. difficile toxin B mRNA in 16 of 30 fecal samples (53.3%) from healthy human adults. In contrast, we failed to detect toxin B in the same fecal samples by PCR using DNA templates extracted with phenol-chloroform. Our results suggest that PCR inhibitors in feces carried through phenol-chloroform extraction procedure might suppress the sensitivity of PCR and that C. difficile is actually present in human gut microbiota more frequently than previously suspected.

The effect of probiotics on clostridium difficile diarrhea

Clostridium difficile is the leading cause of nosocomially acquired intestinal infection in the United States, affecting virtually all cases of pseudomembranous colitis and up to 20% of cases of antibiotic-associated diarrhea. Even after receiving antibiotic treatment with either metronidazole or vancomycin, 20% of patients will have recurrent Clostridium difficile diarrhea. An innovative approach to the problem involves the introduction of competing, nonpathogenic (probiotic) organisms into the intestinal tract to restore microbial balance. The theoretical premise behind this approach is that the protective intestinal microflora is damaged by antibiotic treatment; the initial antibiotic exposure thus leaves the host susceptible to colonization and subsequent infection by Clostridium difficile. A so-called “second-hit” to the intestinal microflora occurs when the infected host is treated with flagyl or vancomycin, further destroying susceptible bacterial flora. Probiotic agents, such as Lactobacillus GG and Saccharomyces boulardii, have been studied for the treatment of Clostridium difficile. We are currently running a prospective, randomized, placebo-controlled trial of Lactobacillus GG in combination with standard antibiotics for the treatment of Clostridium difficile infection. Although it is too early to draw statistically significant conclusions, two patterns seem to be emerging: Lactobacillus GG is effective in reducing the 3-wk recurrence rate of Clostridium difficile, and patients feel better when taking Lactobacillus GG, as compared with the placebo, with early disappearance of abdominal cramps and diarrhea. In conclusion, the use of probiotics for the treatment of primary and recurrent Clostridium difficile diarrhea looks promising. Patients seem to have less recurrent Clostridium difficile diarrhea and early symptomatic improvement when using the probiotic Lactobacillus GG.

The role of antimicrobial agents in the aetiology of Clostridium difficile-associated disease.

High Clostridium difficile disease rates were originally associated with clindamycin use, but this association has declined in recent years following the decline in the clinical use of clindamycin, and disease is now particularly associated with the use of broad-spectrum antibiotics, especially the cephalosporins. There are now sufficient reports in the literature to merit the discontinuation of the widespread use of cephalosporins, especially in the elderly, by the substitution, wherever possible, with antibiotics not associated with the promotion of C. difficile-associated disease. Such agents include benzylpenicillin, gentamicin, trimethoprim, ciprofloxacin and the ureido-penicillins. Widespread education about the proper use of antibiotics in clinical practice remains essential.

抗菌剤投与後の<I>Clostridium difficile</I>検出に対する生菌性整腸剤の併用について

Fecal flora of the patients without remarkable gastrointestinal diseases were studied. All patients were treated with antimicrobial drugs with or without Miya-BM (the preparation of Clostridium butyricum M588). The stools were examined before and after (during) antimicrobial treatment. Fecal flora of 69 patients before medication was almost the same with that of healthy adults as has been reported by Mitsuoka et al. After giving antimicrobials, most bacterial genus except Enterococcus and Yeasts in the stool decreased their detection rate and their population. This floral change was not much influenced by co-administration of Miya-BM. The detection rate of Clostridium difficile and/or the toxin A from the stool were markedly increased after giving antimicrobials. When Miya-BM was co-administered with antimicrobials, however, the detection of C. difficile and/or toxin A was very rare. C. butyricum M588 was recovered from 7 cases out of 10 patients treated with antimicrobials and Miya-BM. Non-spore form of C. butyricum was dominant in the feces of 3 cases, and spore form was dominant in the other 4. This result showed that administered C. butyricum M588 germinated in intestinal tract.

Clostridium difficilein Healthy Adults: Evaluation of Carriage Using an Enrichment Medium

In order to establish the carriage rate of Clostridium difficile in healthy adults, stool samples from 172 healthy subjects were cultured by two different media (CCFA, a selective agar, and GCC, an enrichment selective broth). Two specimens were positive for C. difficile by GCC broth corresponding to an isolation rate of 1.16 per cent. The faecal specimens were negative for the presence of C. difficile cytotoxin and negative by the latex agglutination test for detection of C. difficile . The two isolates were non-cytotoxic and showed two distinct protein profiles different from the patterns characteristic of patients with disease and of neonates. Keywords: C. difficile ; Intestinal carriage; Enrichment culture.

Gastrointestinal carriage rate of Clostridium difficile in elderly, chronic care hospital patients

The carriage rate of Clostridium difficile in patients at a chronic care hospital was determined by two point prevalence surveys at 6-monthly intervals. In the first survey C. difficile or its toxin was present in stool samples from five symptomless patients on three of the four wards studied. All of these colonized patients had been in hospital for at least 2 months, but there was no relationship between carriage of the organism and antibiotic use. When the survey was repeated 6 months later, no symptomless carriers were found but one symptomatic patient had C. difficile and its toxin present in the stool. The results suggest that C. difficile should always be considered as a possible cause of diarrhoea in long-stay hospitalized patients.