Epidemiology Of Clostridium Difficile Infection Research Articles

Epidemiology of Clostridium difficile Infection in the Lung Transplant Population at a High Volume Transplant Center

Introduction:Clostridium difficile infection (CDI) is a leading cause of health care-associated infections in the United States. Significant risk factors for CDI include antibiotic and hospital exposure. Immunosuppression increases susceptibility to CDI. In the lung transplant (LTx) population, incidence of CDI ranges from 6-22.5%. We aim to provide an update on epidemiology of post-operative CDI in the LTx population in a high-volume lung transplant center. Methods: Adult patients who received a LTx at our institution from January 2014-January 2018 were identified and charts were reviewed for a positive PCR assay for CDI (CDI+) after LTx. We also collected relevant demographic and treatment data to make comparisons between the CDI+ and non-CDI (CDI-) populations. Statistics, including t-tests, chi-square and logistic regression were performed with SPSS v25.0. Results: A total of 376 patients underwent LTx during the study period. The overall incidence of CDI post-LTx was 6.4% (24/376 patients). Post-LTx CDI- and CDI+ patients were similar in terms of gender (67% vs 54% male, p=0.20), mean age at time of transplant (64 vs 61 years, p=0.18), race (76% vs 79% Caucasian, p=0.40) and mean Lung Allocation Score (LAS) (50 vs 52, p=0.77). Indication for transplant was significantly different between groups (p=<0.001), namely because there were no CDI+ patients with primary pulmonary hypertension. Of the 24 CDI+ patients, 11 had incident CDI on the same admission as LTx (average time post-LTx: 31 days) and 13 had infection at a subsequent admission (average time post-LTx: 303 days). Seventeen patients had 1 episode of CDI, four patients had 1 recurrence, and 3 patients had multiple recurrences. Most patients (96%) received peri-operative antibiotics for longer than 3 days after transplant. In terms of disease severity, 71% had mild-moderate CDI, 16.5% had severe CDI, and 12.5% had severe/complicated CDI. There were no deaths from CDI. In a logistic regression model, no available risk factor predicted the development of CDI. Conclusion: In our large LTx cohort, the incidence of CDI post-LTx was low compared to other studies. There were no obvious predictors for development of CDI in this population. Interestingly, age at time of LTx and LAS were similar in both groups. Further studies are warranted to further examine the effect of CDI on the morbidity and mortality of LTx patients.

Clinical epidemiology of Clostridium difficile infection among hospitalized patients with antibiotic-associated diarrhea in a university hospital of Brazil

A cohort of 110 adult individuals was analyzed to compare clinical characteristics of hospitalized patients who received antibiotics and developed Clostridium difficile infection (CDI) with those who received antibiotics and did not develop the disease in a university Hospital in Brazil. CDI was diagnosed by toxigenic culture and C. difficile isolates were characterized by PCR ribotyping. Stool samples were also screened for Clostridium perfringens, methicillin-resistant Staphylococcus aureus (MRSA) and Klebsiella oxytoca. The prevalence of CDI among patients with AAD was 31.8%. C. difficile diarrhea was significantly associated with the severity of underlying comorbidities at admission (OR = 1.21; 95% CI, 1.04–1.40) and with the number of antibiotics used during hospitalization (OR = 1.43; 95% CI, 1.07–1.92). Diabetes mellitus was markedly associated with a higher risk of death in patients with AAD (OR = 6.38; 95% CI, 1.33–30.7). PCR ribotypes 014/020 and 106 (20.6% each) were the most common among the isolates. Binary toxin-encoding gene (cdtB) was detected in six samples, but previously described hypervirulent ribotypes 027 and 078 were not found. K. oxytoca and enterotoxigenic C. perfringens were not detected, while only one patient (0.9%) was positive for MRSA. Our results indicate that comorbidity severity and the number of antibiotics used during hospitalization are strong independent predictors of nosocomial C. difficile diarrhea. Diabetes was associated with a higher mortality among patients with AAD. A huge diversity of C. difficile ribotypes was observed in our study, although classical hypervirulent strains were not observed.

Clostridium difficile infection: underestimation or over estimation of the problem?

Background: C. difficile accounts for 20%–30% of cases of antibiotic-associated diarrhea and is the most commonly recognized cause of infectious diarrhea in healthcare settings. The epidemiology of Clostridium difficile infection (CDI) changed in the last years. The objectives were to evaluate the dimension of the problem in the institution and estimate the risks of CDI. Methods & Materials: We conducted a prospective study between January-September 2017. We evaluated all samples entered into the Microbiology Laboratory for the search of CDI. We used the definition of diarrhea and episodes considered mild-moderate or severe/severe-complicated, published in CDI-SHEA/IDSA guidelines 2010 Demographic data, risk factors, severity of infection, treatment and resolution were evaluated. All clinical and demographic data were extracted manually from the electronic medical record. Results: There were 285 samples, 40.70% (116) did not meet the criteria for the definition of diarrhea. In the remaining 59.3% (169), 24 episodes of CDI were documented (14.2%). Higher incidence of infection were in women (66.7%, 16/24), older than 64 years (79.2%, 19/24), use of gastric protection (70.83%, 17/24), previous hospitalization (50%; 12/24) and previous use of ATB (75%; 18/24). 70.8% (17) were mild-moderate, 25% (6) severe and one severe-complicated. The majority received simple treatment with oral metronidazole (66.67%; 16/24) with recovered in 91.7% (22/24) of the cases. In 12.5% there was recurrence. The greatest risk of CDI was the previous use of ATB (OR: 3.93; CI95% 1,46-10.33; p0.006). Conclusion: The suspicion of infection was overestimated and many of the samples analyzed didńt meet the criteria for diarrhea. The incidence of infection was 14.2%. The advanced age was one of the most important risk factors for CDI (more than 4-fold higher in older than 64y). The most important modifiable risk factor for the development of CDI was exposure to antimicrobial agents.

Clostridium difficile infection in two large centers of Lyon University Hospital: Data from 2015 through 2017

Introduction The epidemiology of Clostridium difficile infection (CDI) has changed with an increase in incidence and severity. CDI is a serious medical condition, associated with a substantial morbidity and mortality, as well as costs, particularly in recurrent cases. The aim of this study was to estimate the incidence and the rate of recurrence in two centers of Lyon University Hospital (LUH). Methods A 3-year prospective surveillance was implemented in two centers of LUH: Group (G)1 (Edouard-Herriot Hospital) and Group 2 (Louis-Pradel Hospital, Pierre-Wertheimer Hospital and Femme–Mere-Enfant Hospital). Children (patients Results Between 2015 and 2017, 349 CDI cases were included in this study (G1: 262 and G2: 70 patients). The mean incidence of CDI episodes progressively decreased from 0.94 in 2015 to 0.66 per 1000 HP in 2017 (decrease by 47%). CDI episodes mostly occurred in patients > 65 years of age (61.6%). Men slightly outnumbered women (50.7% and 49.3% respectively). A total of 279 (79.9%) had received antibiotics within one month preceding the onset of diarrhea. Free toxins were detected in 172 episodes (49.3%) and 177 episodes (50.7%) were confirmed by PCR. Most of the episodes were healthcare-associated (79.9%). The remaining cases were community-acquired (17.2%) and unknown (2.9%). No outbreaks and/or epidemic strain 027 were observed in this study. Over the study period, relapse within 60 days after diagnosis was observed in 26 patients (7.4%) and two of them experienced multiple relapse (7.7%). A total of 331 patients (94.8%) were specifically treated for CDI. Monotherapy management included metronidazole (n = 217, 65.6%), vancomycin alone (n = 52, 15.7%), or fidaxomicin (n = 5, 1.5%). A combination or sequential administrations of two or three of them were needed in 15.7% and 1.5%, respectively. The comparison between the 2 centers showed that patients in G1 were older (median of 74 vs. 67 years in G2, P

Healthcare-associated Clostridium difficile infection: role of correct hand hygiene in cross-infection control.

Clostridium difficile (CD) is the most common cause of health-care-associated infectious diarrhea with increasing incidence and severity in recent years. The main cause of hospital's acquired cross infections can be attributed to incorrect hand hygiene. We described the epidemiology of CD infection (CDI) in a teaching hospital in Southern Italy during a two years surveillance period and evaluated the health-care workers compliance to hand hygiene. CDI Incidence rates were calculated as the number of patients with positive C. difficile toxin assay per 10,000 patient-days. Compliance with hand hygiene was the ratio of the number of performed actions to the number of opportunities observed. Approximately 400 Hand Hygiene (HH) opportunities/year /ward were observed. We finally checked out if any correlation could be found. From January 2015 to December 2016 a total number of 854 CD determinations were performed in patients with clinical symptoms of diarrhea. The search for toxins A and B was positive in 175 cases (21,2%), confirming the diagnosis of CDI. Compliance to hand hygiene was significantly inversely associated with the number of CDIs: the lower the compliance of health-care workers with hand hygiene the higher was the number of cases of CDIs (p = 0.003). According to our results proper handwashing of health-care workers appears to be a key intervention in interrupting CD cross infections regardless of age and type of department in which the patient is admitted.

Molecular epidemiology and antimicrobial susceptibility of human Clostridium difficile isolates from a single institution in Northern China.

Because the epidemiology of Clostridium difficile infection (CDI) is region-specific, the present study was undertaken to examine the epidemiology of C difficile outbreaks in Beijing, China.Eighty nonduplicate isolates were collected from March, 2016 to December, 2016. The molecular type and phylogenetic analysis were evaluated by multilocus sequence typing (MLST). The minimum inhibitory concentrations (MICs) for 11 antibiotics and the resistance mechanisms were investigated.Sixty-five toxigenic strains (81.25%), including 22 tcdA-B+CDT- strains (27.5%) and 43 tcdA+B+CDT- strains (53.75%), and also 15 nontoxigenic strains (tcdA-B-CDT-; 18.75%) were detected. MLST identified 21 different sequence types (STs), including 2 novel types (ST409 and ST416). All isolates were susceptible to metronidazole, vancomycin, fidaxomicin, piperacillin/tazobactam, and meropenem, and all were effectively inhibited by emodin (MICs 4–8 μg/mL). The resistance rates to rifaximin, ceftriaxone, clindamycin, erythromycin, and ciprofloxacin were 8.75%, 51.25%, 96.25%, 81.25%, and 96.25%, respectively; 81.25% (65/80) of isolates were multidrug-resistant. Amino acid mutations in GyrA and/or GyrB conferred quinolone resistance. One novel amino acid substitution, F86Y in GyrA, was found in 1 CIP-intermediate strain. The erm(B) gene played a key role in mediating macrolide-lincosamide-streptogramin B (MLSB) resistance. Erm(G) was also found in erm(B)-negative strains that were resistant to both erythromycin and clindamycin. RpoB mutations were associated with rifampin resistance, and 2 new amino mutations were identified in 1 intermediate strain (E573A and E603N).Regional diversity and gene heterogeneity exist in both the ST type and resistant patterns of clinical C difficile isolates in Northern China.

C. difficile Infection in Children: What’s New?

The purpose of this review is to present the epidemiology of Clostridium difficile infection in children and to present a number of clinical challenges in diagnosis and therapy that are unique to the pediatric population. Current research has focused on novel methods of prevention and treatment of C. difficile infection in children. Fecal microbial transplantation (FMT) for recurrent C. difficile is increasingly prescribed for children, and recent data includes comparisons of effectiveness and tolerability between methods of delivery. The incidence of C. difficile infection in children has risen in recent decades both in healthy children and those with underlying comorbidities. Antibiotic use, acid suppressive medication use, and the presence of enteric feeding tubes are well-documented risk factors. There is no standard method of testing for C. difficile infection in children, which complicates epidemiological tracking and detection of active disease versus asymptomatic colonization. First-line therapy for initial infection in children is metronidazole, while vancomycin may be reserved for those with severe infection or high risk of complications. Recurrence of infection is frequent, and while repeat courses of antibiotics may be effective, fecal microbial transplant should be considered a safe and efficacious alternative therapy.

Secular trends in the epidemiology of Clostridium difficile infection (CDI) at a tertiary care hospital in Barcelona, 2006–2015: A prospective observational study

ObjectiveDescribe secular trends in the epidemiology and outcome of Clostridium difficile infection (CDI) at a tertiary hospital. MethodsAll consecutive primary CDI episodes in adults (January 2006–December 2015) were included. CDI was diagnosed on the presence of diarrhoea and a positive stool test for C. difficile toxin A and/or B. To define trends, a time-series analysis was performed using yearly data on demographics, clinical characteristics, management, antimicrobial treatment, and outcome of CDI. Patients were followed-up for three months after the diagnosis. ResultsThere were 724 CDI episodes. Over the period from 2006 to 2015, the incidence rose from 0.18 episodes/1000 admissions to 0.26 episodes (relative rate [RR] 1.43; 95%CI, 1.02–2.00; P = 0.035). Median Charlson comorbidity index increased from 2 (IQR 1–3) to 4 (IQR 2–4) (RR 1.65; 95%CI, 1.12–2.41; P = 0.005). Overall, 80.4% of patients received proton pump inhibitors (PPIs) prior to CDI, and the percentage of PPI discontinuations rose from 2.3% to 20.4% (RR 8.80; 95%CI 1.20–64.36; P = 0.006). Management of non-Clostridium antibiotics also changed: antibiotic withdrawals or switches increased from 4.2% to 29.2% (RR 7.00; 95%CI 1.68–29.15, P = 0.001). Regarding CDI treatment, the percentage of patients treated with metronidazole decreased (88.9% vs 52.6%) (RR 0.59 (0.48–0.73), P < 0.001), whereas the percentage receiving vancomycin increased (1.9% vs 32.6%) (RR 17.62 (2.47–125.49), P < 0.001). The percentages of cures, deaths, and first recurrences did not significantly change over the 10-year period. ConclusionsChanges in CDI management were associated with a stable prognosis (percentage of cures and first recurrences), even though affected patients had a greater number of comorbidities over time.

Molecular epidemiology of Clostridium difficile in two tertiary care hospitals in Shandong Province, China.

PurposeThe incidence and severity of Clostridium difficile infection (CDI) have markedly increased over the past decade. However, there is very limited epidemiological data on CDI in China so far, specifically no data in Shandong Province. The aim of this study was to evaluate diagnostic algorithm for CDI and to gain data on molecular epidemiology of CDI in the Shandong Province of China.Materials and methodsNonrepetitive unformed fecal specimens (n=504) were investigated by the glutamate dehydrogenase (GDH), C. difficile toxin A&B (CDAB) tests and toxigenic culture. Furthermore, 85 isolates were characterized by toxin gene detection, multilocus sequence typing, ribotyping and antimicrobial susceptibility testing.ResultsThe algorithm of combining GDH and CDAB tests could define diagnosis of 54.2% CDI cases and excluded 90% of non-CDI. Further adding the toxigenic culture to the algorithm enhanced the detection sensitivity to 100%. Toxigenic strains comprised 84.7% of isolates, including A+B+CDT− (71.8%, 61/85), A−B+CDT− (11.8%, 10/85) and A+B+CDT+ (1.2%, 1/85) isolates. RT046/ST35 (13.9%, 10/72), RT014/ST2 (12.5%, 9/72) and RT017/ST37 (12.5%, 9/72) were the more common genotypes among toxigenic C. difficile strains. The clinical severity score of A−B+CDT− toxin genes genotype (3.50±0.85) was significantly higher than the A+B+CDT− type (2.59±0.93) (P<0.05). RT046/ST35 isolates were highly prevalent and had high clinical severity scores (3.80±0.92). Variations in resistance from different sequence types (STs) were observed. Toxigenic strains showed higher resistance rates to erythromycin, clindamycin and ciprofloxacin compared to nontoxigenic strains (P<0.05).ConclusionThe epidemiology of C. difficile in Shandong Province differed from other regions in China. Comprehensive optimized diagnosis strategy and continuous surveillance should be established and applied in order to curb the spread of toxigenic C. difficile strains, especially for hospitalized patients.

Molecular epidemiology and antimicrobial resistance of Clostridium difficile in a national geriatric hospital in Costa Rica

The epidemiology of Clostridium difficile infections (CDI) is changing rapidly worldwide; knowledge on the genotypes of C.difficile circulating in specialized geriatric hospitals and their resistance to antibiotics is scarce or non-existent. Prospective study of the molecular epidemiology of CDI, conducted in a national geriatric hospital in Costa Rica for a period of 11 months. The study patients exhibited a diverse range of comorbidities, but none were associated with CDI. Polyclonality, including three new ribotypes, and a high level of resistance to antibiotics were determined by analysing the 32 isolates obtained in these cases. Despite the diversity in strains observed, the most frequent types were NAP6/RT002 and NAP2/RT001. NAP9/RT017 was associated with community acquisition. Nineteen types of antimicrobials were used before the onset of diarrhoea in the patients; no particular genotype was associated with the onset of infection or severity. Based on the abundance of strain types observed and their resistance to antibiotics in this geriatric hospital, these results contribute to a better overall understanding of the epidemiology of CDI worldwide, and to surveillance programmes targeting geriatric populations.

Epidemiology and outcomes of Clostridium difficile infection in allogeneic hematopoietic cell and lung transplant recipients.

Clostridium difficile infection (CDI) is a common complication of lung and allogeneic hematopoietic cell (HCT) transplant, but the epidemiology and outcomes of CDI after transplant are poorly described. We performed a prospective, multicenter study of CDI within 365days post-allogeneic HCT or lung transplantation. Data were collected via patient interviews and medical chart review. Participants were followed weekly in the 12weeks post-transplant and while hospitalized and contacted monthly up to 18months post-transplantation. Six sites participated in the study with 614 total participants; 4 enrolled allogeneic HCT (385 participants) and 5 enrolled lung transplant recipients (229 participants). One hundred and fifty CDI cases occurred within 1year of transplantation; the incidence among lung transplant recipients was 13.1% and among allogeneic HCTs was 31.2%. Median time to CDI was significantly shorter among allogeneic HCT than lung transplant recipients (27days vs 90days; P=.037). CDI was associated with significantly higher mortality from 31 to 180days post-index date among the allogeneic HCT recipients (Hazard ratio [HR]=1.80; P=.007). There was a trend towards increased mortality among lung transplant recipients from 120 to 180days post-index date (HR=4.7, P=.09). The epidemiology and outcomes of CDI vary by transplant population; surveillance for CDI should continue beyond the immediate post-transplant period.

The Recent Emergence of Clostridium difficile Infection in Romanian Hospitals is Associated with a High Prevalence of Polymerase Chain Reaction Ribotype 027.

Aims:To investigate the epidemiology of Clostridium difficile infection in Romanian hospitals.Methods:A survey was conducted at nine hospitals throughout Romania between November 2013 and February 2014.Results:The survey identified 393 patients with Clostridium difficile infection. The median age was 67 years (range: 2-94 years); 56% of patients were aged >65 years. The mean prevalence of Clostridium difficile infection was 5.2 cases per 10.000 patient-days. The highest prevalences were 24.9 and 20 per 10.000 patient-days in hospitals specializing in gastroenterology and infectious diseases, respectively. Clostridium difficile infections were health care-associated in 70.5% patients and community-acquired in 10.2%. The origin was not determined in 19.3%. Clostridium difficile infection was severe in 12.3% of patients, and the in-hospital all-cause mortality was 8.8%. Polymerase chain reaction ribotype 027 had the highest prevalence in all participating hospitals and represented 82.6% of the total ribotyped isolates. The minimum inhibitory concentration of moxifloxacin was >4 μg/mL for 59 of 80 tested isolates (73.8%). Of 59 isolates, 54 were highly resistant to moxifloxacin (minimum inhibitory concentration ≥32 μg/mL), and the majority were polymerase chain reaction ribotype 027 (p<0.0001).Conclusion:The ribotype 027 was the predominant cause of Clostridium difficile infections in Romania. In some specialized hospitals, the prevalence of Clostridium difficile infection was higher than the European mean prevalence, and this demonstrates the need for strict adherence to infection control programs.

New Insights into Clostridium difficile (CD) Infection in Latin America: Novel Description of Toxigenic Profiles of Diarrhea-Associated to CD in Bogotá, Colombia.

Clostridium difficile (CD) produces antibiotic associated diarrhea and leads to a broad range of diseases. The source of CD infection (CDI) acquisition and toxigenic profile are factors determining the impact of CD. This study aimed at detecting healthcare facility onset- (HCFO) and community-onset (CO) CDI and describing their toxigenic profiles in Bogotá, Colombia. A total of 217 fecal samples from patients suffering diarrhea were simultaneously submitted to two CDI detection strategies: (i) in vitro culture using selective chromogenic medium (SCM; chromID, bioMérieux), followed verification by colony screening (VCS), and (ii) molecular detection targeting constitutive genes, using two conventional PCR tests (conv.PCR) (conv.16S y conv.gdh) and a quantitative test (qPCR.16s). The CD toxigenic profile identified by any molecular test was described using 6 tests independently for describing PaLoc and CdtLoc organization. High overall CDI frequencies were found by both SCM (52.1%) and conv.PCR (45.6% for conv.16S and 42.4% for conv.gdh), compared to reductions of up to half the frequency by VCS (27.2%) or qPCR.16S (22.6%). Infection frequencies were higher for SCM and conv.16S regarding HCFO but greater for CO concerning conv.gdh, such differences being statistically significant. Heterogeneous toxigenic profiles were found, including amplification with lok1/3 primers simultaneously with other PaLoc markers (tcdA, tcdB or tcdC). These findings correspond the first report regarding the differential detection of CDI using in vitro culture and molecular detection tests in Colombia, the circulation of CD having heterogeneous toxigenic profiles and molecular arrays which could affect the impact of CDI epidemiology.

The Need for European Surveillance of CDI.

Since the turn of the millennium, the epidemiology of Clostridium difficile infection (CDI) has continued to challenge. Over the last decade there has been a growing awareness that improvements to surveillance are needed. The increasing rate of CDI and emergence of ribotype 027 precipitated the implementation of mandatory national surveillance of CDI in the UK. Changes in clinical presentation, severity of disease, descriptions of new risk factors and the occurrence of outbreaks all emphasised the importance of early diagnosis and surveillance.However a lack of consensus on case definitions, clinical guidelines and optimal laboratory diagnostics across Europe has lead to the underestimation of CDI and impeded comparison between countries. These inconsistencies have prevented the true burden of disease from being appreciated.Acceptance that a multi-country surveillance programme and optimised diagnostic strategies are required not only to detect and control CDI in Europe, but for a better understanding of the epidemiology, has built the foundations for a more robust, unified surveillance. The concerted efforts of the European Centre for Disease Prevention and Control (ECDC) CDI networks, has lead to the development of an over-arching long-term CDI surveillance strategy for 2014-2020. Fulfilment of the ECDC priorities and targets will no doubt be challenging and will require significant investment however the hope is that both a national and Europe-wide picture of CDI will finally be realised.

Epidemiology of Clostridium Difficile Infection in a Large Hospital in Northern Italy: Questioning the Ward-Based Transmission.

Background: Clostridium Difficile infection (CDI) is considered a ward-based nosocomial infection, due to contagion among patients. Molecular studies recently questioned ward-based contact for disease spread.Objective:To investigate whether it is plausible that CDI spread in San Martino Hospital of Genoa was due to a ward-based contact and patient-to-patient diffusion.Methods:We conducted a retrospective cohort study of CDI cases from April 2010 to March 2015. We referred to Hospital data set and Admission Service. Multilevel modelling approach and ecological analysis were used to assess C. difficile infection risk according to wards and time of occurrence. Six representative CD strains were ribotyped to assess a possible equivalence.Results:The assessment of 514 CDI cases showed that the risk of disease and rate of incidence in wards were independent, while frequency of cases and number of wards involved exhibited a positive relationship, excluding the typical epidemic pattern of contagious diffusion, i.e., many cases in few wards. The extra-binomial variability due to ward clustering was not significant, indicating homogeneity in the probability of CDI occurrence across all wards. Three hundred sixty-eight patients changed ward, without showing connection between the frequency of cases in new wards and incidence among new subjects. Trigonometric components described a significant contribution of seasonality, with excess of CDI cases during the winter months. Molecular analysis showed different ribotypes of CD strains from the same ward.Conclusion:From our results it seems unlikely that in our institution CDI occurrence is due to ward-based contact and inter-human contagion of the organism.

National epidemiology of initial and recurrent Clostridium difficile infection in the Veterans Health Administration from 2003 to 2014.

IntroductionPrior studies demonstrated marked increases in Clostridium difficile infection (CDI) in the United States (U.S.) in recent years. The objective of this study was to describe the epidemiology of initial and recurrent CDI in a national Veterans Health Administration (VHA) cohort over a 12-year period.MethodsThis was a retrospective cohort study of all adult VHA beneficiaries with CDI (ICD-9-CM code 008.45) plus a positive CDI stool test between October 1, 2002 and September 30, 2014. Data were obtained from the VA Informatics and Computing Infrastructure. Recurrence was defined as a second ICD-9-CM code plus a new course of CDI therapy following a minimum three-day gap after the initial therapy was completed. CDI incidence and outcomes were presented descriptively and longitudinally.ResultsOverall, 30,326 patients met study inclusion criteria. CDI incidence increased from FY 2003 (1.6 per 10,000) to FY 2013 (5.1 per 10,000). Thereafter, CDI incidence decreased through FY 2014 (4.6 per 10,000). A total of 5,011 patients (17%) experienced a first recurrence and, of those, 1,713 (34%) experienced a second recurrence. Recurrence incidence increased 10-fold over the study period, from (0.1 per 10,000) in FY 2003, to (1.0 per 10,000) in FY 2014. Overall, 30-day mortality and median hospital length of stay (LOS) decreased among initial episodes over the study period. Mortality was higher for initial episodes (21%) compared to first recurrences (11%) and second recurrences (7%). Median hospital LOS was longer for first episodes (13 days) compared to first (9 days) and second recurrences (8 days).ConclusionsInitial and recurrent CDI episodes increased among veterans over a 12-year period. Outcomes, such as mortality and hospital LOS improved in recent years; both of these outcomes are worse for initial CDI episodes than recurrent episodes.

Surveillance of antibiotic resistance among common Clostridium difficile ribotypes in Hong Kong

Incidence of Clostridium difficile infection (CDI) is rapidly increasing and it poses a major health burden globally. However, data regarding the epidemiology of CDI in Asia are limited. We aimed to characterize the antimicrobial susceptibility patterns of common ribotypes of toxigenic C. difficile in Hong Kong. Fifty-three PCR ribotypes were identified among 284 toxigenic C. difficile clinical isolates. The five most prevalent ribotypes were 002 (13%), 017 (12%), 014 (10%), 012 (9.2%), and 020 (9.5%). All tested C. difficile strains remained susceptible to metronidazole, vancomycin, meropenem and piperacillin/tazobactam, but highly resistant to cephalosporins. Of the fluoroquinolones, highest resistance to ciprofloxacin was observed (99%), followed by levofloxacin (43%) and moxifloxacin (23%). The two newly emerged PCR ribotypes, 017 and 002, demonstrated high levels of co-resistance towards clindamycin, tetracycline, erythromycin and moxifloxacin. PCR ribotypes 017 and 002 with multi-drug resistance are rapidly emerging and continuous surveillance is important to monitor the epidemiology of C. difficile to prevent outbreaks of CDI.

Clostridium difficile infections in a university hospital in Greece are mainly associated with PCR ribotypes 017 and 126.

Data regarding the incidence and molecular epidemiology of Clostridium difficile infections (CDIs) in Greece are limited. A retrospective study of all laboratory-confirmed CDI cases in a university hospital during a 9-month period. Stool samples from inpatients with diarrhoea were tested with a combined glutamate dehydrogenase (GDH) and toxin enzyme immunoassay (EIA) test, as part of a two-step algorithm for CDI testing. All GDH-positive samples were cultured and isolates were further tested for the presence of toxin genes and characterized by PCR ribotyping. The incidence of CDI in our hospital was 25 per 10 000 hospital admissions. Of 33 CDI cases, 72.7 % were hospital-acquired. Fourteen different PCR ribotypes were identified, of which 017 (21.2 %), 078/126 (15.1 %) and RT202 and RT106 (9 %) were the most prevalent. Most patients had a risk profile of recent antibiotic use, older age and comorbidities. Despite mild CDI clinical characteristics, six cases showed complications and led to 18.2 % mortality. The CDI incidence was comparable to that in other European countries. The hypervirulent PCR ribotype 027 was not found, whereas ribotypes 017 and 126 predominated. Most CDI cases were in patients who used antibiotics, emphasizing that antimicrobial stewardship should be considered as a cornerstone for the prevention of CDI.

Clostridium difficile causing pediatric infections: New findings from a hospital-based study in Italy

Recent studies support a change of Clostridium difficile infections (CDIs) epidemiology in pediatric patients. Since limited information is available about C. difficile in this population, we investigated the epidemiology of CDI in a large pediatric hospital that acts as reference centre in Italy and analyzed C. difficile isolates to identify the prevalent PCR-ribotypes (RTs), the binary toxin (CDT)-positive strains and the antibiotic susceptibility patterns. The CDI incidence was 6.6 cases/1000 admissions and the majority (92%) of CDI were healthcare-associated (47% occurred in the Hematology-Oncology and in the Gastroenterology units). Most of symptomatic children <3 years with a positive culture for C. difficile were negative for other gastrointestinal pathogens, supporting C. difficile as cause of disease in these patients, including those showing recurrences. Strains RT020 (16%) and RT014 (14%) were identified as the main cause of infection, while RT356/607 and RT018, predominant in Italian adult patients, were absent (RT356/607) or rarely found (RT018) among children. CDT-positive strains represented the 20% of the total number of isolates analyzed. In particular, two emerging types, RT033 and RT442, were recognized as Toxin A-/Toxin B-/CDT+. Resistance to antibiotics characterized almost 50% of the toxigenic isolates analyzed in this study and, in particular, 20% of them were multidrug resistant (MDR). The emergence and circulation of strains with peculiar toxins profiles and/or MDR strongly highlight the necessity of a rapid CDI diagnosis, a careful monitoring of C. difficile in pediatric patients and a more strict control of antibiotics usage in the Italian pediatric hospitals.

The ClosER study: results from a three-year pan-European longitudinal surveillance of antibiotic resistance among prevalent Clostridium difficile ribotypes, 2011–2014

ObjectivesUntil the introduction of fidaxomicin, antimicrobial treatment for Clostridium difficile infection (CDI) was limited to metronidazole and vancomycin. The changing epidemiology of CDI and the emergence of epidemic C. difficile PCR ribotype 027 necessitate continued surveillance to identify shifts in antibiotic susceptibility. ClosER, currently the largest pan-European epidemiological study of C. difficile ribotype distribution and antibiotic susceptibility, aimed to undertake antimicrobial resistance surveillance pre- and post-introduction of fidaxomicin. MethodsBetween July 2011 and July 2014, 39 sites across 22 European countries submitted 2830 C. difficile isolates for ribotyping, toxin testing and susceptibility testing to metronidazole, vancomycin, fidaxomicin, rifampicin, moxifloxacin, clindamycin, imipenem, chloramphenicol and tigecycline. ResultsRibotypes 027, 014, 001, 078, 020, 002, 126, 015 and 005 were most frequently isolated, and emergent ribotypes 198 and 356 were identified in Hungary and Italy, respectively. All isolates were susceptible to fidaxomicin, with scarce resistance to metronidazole (0.2%, 6/2694), vancomycin (0.1%, 2/2694) and tigecycline (0%). Rifampicin, moxifloxacin and clindamycin resistance was evident in multiple ribotypes. Lack of ribotype diversity correlated with greater antimicrobial resistance. Epidemic ribotypes (027/001) were associated with multiple antimicrobial resistance, and ribotypes 017, 018 and 356 with high-level resistance. Additional factors may also influence local ribotype prevalence. ConclusionsFidaxomicin susceptibility was retained post-introduction, and resistance to metronidazole and vancomycin was rare. Continued surveillance is needed, with more accurate classification and clarification of ribotype subtypes to further understand their role in the spread of resistance. Other factors may also influence changes in prevalence of C. difficile ribotypes with reduced antibiotic susceptibility.