Incidence Of Clostridium Difficile Research Articles

Antimicrobial Selection and Its Impact on the Incidence of Clostridium difficile–Associated Diarrhea

The study objective was to determine which antimicrobials place patients at a higher risk for Clostridium difficile–associated diarrhea (CDAD) and which interventions can reduce their risk. All patients with diarrhea and a positive toxin assay for Clostridium difficile for 3 months were included in the study. Patients were broken down into either community-acquired infection or health care–associated infection based on symptom onset, antibiotic usage prior to admission, and where the patient was admitted from. Physicians were educated on antimicrobials that place patients at higher risk for CDAD and alternative agents to use. Physician education consisted of in-service presentations, posters, Medical Grand Rounds, and an article in the physician newsletter highlighting the initial results of this study and alternative antimicrobial regimens. After implementation of educational programs, a repeat sample of patients was reviewed to determine effectiveness of the physician education. Cases of CDAD increased secondary to testing changes at our facility. Implicated antimicrobial usage did decrease after educational program implementation.

Reducing Clostridium difficile Incidence, Colectomies, and Mortality in the Hospital Setting: A Successful Multidisciplinary Approach

Health care associated Clostridium difficile infections are a major cause of morbidity and mortality in hospitals. In the United States, from 2000 through 2009, discharge diagnoses from hospitals in the United States that included C. difficile increased from 139,000 to 336,600, and the yearly national excess hospital cost associated with hospital-onset C. difficile is estimated to be upwards of $1.3 billion. A hospitalwide, multidisciplinary approach was undertaken at Rhode Island Hospital (Providence), a tertiary care hospital. The hospital plan entailed six interventions: (1) develop a C. difficile hospital infection control plan based on a risk assessment; (2) monitor hospitalwide morbidity and mortality associated with C. difficile infection; (3) improve sensitivity of C. difficile toxin detection in stool specimens using a polymerase chain reaction-based nucleic acid amplification assay; (4) enhance environmental cleaning of patient rooms and equipment; (5) develop a C. difficile infection treatment plan; and (6) conduct other interventions. The incidence of health care-associated C. difficile infection was assessed from January 2006 through the third quarter of 2012; the number of colectomies and mortality associated with C. difficile infection were determined from January 2005 through the third quarter of 2012. The incidence of health care-associated C. difficile infection decreased from a peak of 12.2/1,000 discharges during the second quarter of 2006 to 3.6/1,000 discharges during the third quarter of 2012. The yearly mortality in patients with health care-associated C. difficile infection was reduced from a peak of 52 in 2006 to 19 in 2011, with 13 such cases in the first three quarters of 2012. A hospitalwide multidisciplinary approach can reduce health care-associated C. difficile infection morbidity and mortality.

Calcineurin inhibitors and Clostridium difficile infection in adult lung transplant recipients: the effect of cyclosporine versus tacrolimus

BackgroundTacrolimus (FK506) has a superior immunosuppressive effect compared with cyclosporine (CSA) without a significant increase in generalized infectious complications. Differences in specific infections such as Clostridium difficile (CDI) have not been reported. We investigated the relationship between calcineurin inhibitors and CDI, hypothesizing that choice of calcineurin inhibitor (CSA or FK506) after lung transplantation would have no effect on the incidence of CDI. MethodsWe performed a retrospective chart review of lung transplant recipients between June 1, 2000, and December 31, 2005, at a single institution. Positive CDI assays through December 11, 2011, were also recorded. We used Student’s t- and chi-squared tests (α = 0.05) to compare CSA and FK506 groups. We calculated adjusted hazard ratios for CDI using Cox proportional hazard models. ResultsWe identified 217 lung transplant recipients: 106 patients in the CSA group and 111 patients in the FK506 group. A total of 31 patients (27.9%) in the FK506 group developed CDI postoperatively compared with 20 patients (18.9%) in the CSA group (P = 0.16). The adjusted hazard ratio for CDI in the FK506 group was not significantly higher (1.53; 95% confidence interval, 0.78–2.98). There was no significant difference in the intensive care unit or total length of stay, in-hospital incidence rate, time to first CDI episode, or recurrence rate between groups. ConclusionsThe CDI rates were not significantly higher in the FK506 group than the CSA group in our study. These data are consistent with previous studies on FK506 that show no increase in infectious complications over CSA, and demonstrate its continued safety in lung transplantation.

Detailed methodological recommendations for the treatment of Clostridium difficile-associated diarrhea with faecal transplantation

The incidence of Clostridium difficile associated enteral disease shows dramatic increase worldwide, with appallingly high treatment costs, mortality figures, recurrence rates and treatment refractoriness. It is not surprising, that there is significant interest in the development and introduction of alternative therapeutic strategies. Among these only stool transplantation (or faecal bacteriotherapy) is gaining international acceptance due to its excellent cure rate (≈92%), low recurrence rate (≈6%), safety and cost-effectiveness. Unfortunately faecal transplantation is not available for most patients, although based on promising international results, its introduction into the routine clinical practice is well justified and widely expected. The authors would like to facilitate this process, by presenting a detailed faecal transplantation protocol prepared in their Institution based on the available literature and clinical rationality. Officially accepted national methodological guidelines will need to be issued in the future, founded on the expert opinion of relevant professional societies and upcoming advances in this field.

Renal impairment after high-dose flucloxacillin and single-dose gentamicin prophylaxis in patients undergoing elective hip and knee replacement

Following advice from the Scottish Antimicrobial Prescribing Group, we switched our antibiotic prophylaxis for elective hip and knee replacement surgery from cefuroxime to flucloxacillin with single-dose gentamicin in order to reduce the incidence of Clostridium difficile associated diarrhoea (CDAD). A clinical impression that more patients subsequently developed acute kidney injury (AKI) led us to examine this possibility in more detail. We examined the incidence of AKI in 198 consecutive patients undergoing elective hip or knee surgery. These patients were given the following prophylactic antibiotics: cefuroxime (n = 48); then high-dose (HD) flucloxacillin (5-8 g) with single-dose gentamicin (n = 52); then low-dose (LD) flucloxacillin (3-4 g) with single-dose gentamicin (n = 46) and finally cefuroxime again (n = 52). Patients receiving HD flucloxacillin required more vasopressors during surgery (P = 0.02); otherwise, there were no statistically significant differences in pre- and peri-operative characteristics between the four groups. The proportion of patients with any form of AKI by RIFLE criteria was first cefuroxime (8%), HD flucloxacillin with gentamicin (52%), LD flucloxacillin with gentamicin (22%) and second cefuroxime (14%; P < 0.0001). Odds ratios for AKI derived from a multivariate logistic regression model, adjusted also for sex and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, with the first cefuroxime group as a reference category were: HD flucloxacillin with gentamicin 14.53 (4.25-49.71); LD flucloxacillin with gentamicin 2.96 (0.81-10.81) and second cefuroxime 2.01 (0.52-7.73). Three patients required temporary haemodialysis. Biopsies in two of these showed acute tubulo-interstitial nephritis. All three patients belonged to the HD flucloxacillin with gentamicin group. None of the patients developed CDAD. We have shown an association between the prophylactic antibiotic regimen and subsequent development of AKI following primary hip and knee arthroplasty that appeared to be due to the use of HD flucloxacillin with single-dose gentamicin. We found no evidence to suggest that this association was confounded by any of the co-variates we measured.

Diarreia associada ao Clostridium difficile - Casuística de 8 anos

IntroductionIn developed countries, Clostridium difficile is responsible for almost all cases of hospital acquired diarrhea and its incidence, morbidity and mortality have increased substantially over the years. The main risk factors implicated are recent antibiotic usage, increasing age and prolonged hospitalization. ObjectivesTo characterize the occurrence of Clostridium difficile associated diarrhea in our institution, in an eight-year period between 2000 and 2008, with the analysis of the potentially implicated risk factors. Material and methodsWe conducted a retrospective study where we considered patients admitted to our institution between January/2000 and December/2008 with the diagnosis of Clostridium difficile associated diarrhea and recorded information regarding risk factors, diagnostic procedures, treatment and complications. For the statistical analysis, t Student test and Fisher's exact test were used. ResultsWe identified 37 cases of Clostridium difficile associated diarrhea in the study period (mean age 76 years), 16 of which occurred in the year 2008. Penicillins, quinolones and cephalosporins were the most commonly involved classes of antibiotics. In 2008, carbapenems were used more frequently (p=0,01), as were the proton pump inhibitors (p=0,02) and the number of complications rose significantly (p=0,01). ConclusionsIn 2008 there was a higher incidence of Clostridium difficile associated diarrhea in our institution. We also encountered an increased use of carbapenems and proton pump inhibitors in that same time period.

Use of a neighboring uninjured nerve for restoration of tissue function

INTRODUCTION AND OBJECTIVES: Clostridium difficile (CD) colitis is at historically high levels, leading to increased complications and costs in patients undergoing major abdominal surgery involving the gastrointestinal tract. We sought to assess if screening and empiric treatment of preoperative asymptomatic CD carriers would decrease symptomatic CD colitis in patients undergoing cystectomy and urinary diversion METHODS: A prospective evaluation of CD carrier status was undertaken in patients undergoing cystectomy and urinary diversion between January-September 2015 by testing stool samples at the time of surgery. Patients identified as CD carriers were treated with intravenous metronidazole until return of bowel function. The incidence of clinically symptomatic CD colitis was assessed in this intention to treat cohort and compared to a retrospective cohort of 562 patients that underwent cystectomy during 2010-2013. RESULTS: A total of 78 patients were included in the intention to treat analysis, of which 62 (79%) were screened intraoperatively for CD. Of those screened, 18 (30%) were asymptomatic carriers of CD. The incidence of patients who developed symptomatic CD colitis in the intention to treat cohort was 3.8% (3/78 patients). Of those 3 patients, 2 were negative for CD preoperatively and 1 was unknown. None of the treated patients developed CD colitis or adverse outcomes. When compared to the historical cohort which had aCD colitis incidence of 8.8%, the relative risk reduction was 57% with a number needed to treat of 20. CONCLUSIONS: Cystectomy patients were found to have a high incidence of asymptomatic CD. Identification and treatment of asymptomatic carriers at time of surgery seems to decrease the incidence of CD colitis. Further studies are warranted to assess the utility and cost of testing for CD status followed with empiric treatment.

Clostridium difficile

This review comprises recent insights on epidemiology, risk factors, diagnostic approaches, pathophysiologic mechanisms, novel treatment options and prevention strategies of Clostridium difficile infection (CDI). Incidence of Clostridium difficile continues to rise and hypervirulent subtypes such as polymerase chain reaction (PCR) ribotype 027 and 078 have emerged worldwide. Children and postpartum women are increasingly recognized as being at risk for development of CDI and community-associated infection is no longer rare. PCR technology may replace complicated two-step test algorithms in the future, because it is rapid, sensitive and specific. Pathophysiological studies have provided evidence that either one of the two exotoxins A and B is important in conferring virulence - the role of binary toxin requires further investigation. Proton pump inhibitors are now established as important risk factors for acquiring, complicating CDI, and developing recurrences. Fidaxomycin, monoclonal antibodies and intestinal microbiota transplantation are promising new treatment options, especially regarding prevention of recurrent disease. Future prevention strategies involve vaccination and novel insights on reservoirs for ongoing transmission, including the food chain. Important advances in research on CDI include novel diagnostic approaches, better understanding of the underlying pathophysiological mechanisms of disease and the development of new approaches to treatment.

Clostridium difficile infection in the pediatric surgery population

PurposeThe incidence of Clostridium difficile–associated disease (CDAD) in the adult population doubled in the past decade, with increasing morbidity and mortality; however, little research has been performed in the pediatric population. We characterized C difficile infection in the pediatric population, with emphasis on the surgical population. MethodsAt a university-based children's hospital, we reviewed 231 patient (birth to 18 years of age) records containing a diagnosis of CDAD between January 1, 2002, and December 31, 2008. ResultsClostridium difficile–associated disease incidence increased from 250 per 100,000 hospitalizations in 2002 to 580 per 100,000 hospitalizations in 2008. No fatalities or surgical interventions were attributable to CDAD. Eighty-seven percent of patients received antibiotics within 2 months of diagnosis. Fifty-two percent of patients underwent operative intervention within 2 months of diagnosis; of these, 89% percent received previous antibiotic therapy and 57% were immunosuppressed. The most common antecedent procedures were bone marrow biopsy and line placement for myelodysplastic diseases (40%), followed by renal transplant (11%). ConclusionsPediatric CDAD incidence doubled during the study period but was not associated with death or operative intervention. A substantial number of CDAD cases were associated with previous operative procedures, particularly in immunosuppressed patients and those who received prior antibiotics.

Clostridium difficile–Associated Diarrhea at a Community Hospital: Ten-Year Analysis of Infection Rates and the Relationship with Proton Pump Inhibitor Use

Purpose To investigate the relationship between proton pump inhibitor (PPI) use and the incidence of Clostridium difficile–associated diarrhea (CDAD) at a community hospital. Methods The number of inpatient admissions, inpatient cases of CDAD, and PPI and antimicrobial doses were collected for each year from 2000 to 2009. Correlations between incidence of CDAD and doses of PPI and antimicrobials were calculated using Spearman's rank correlation coefficient analysis. Results The incidence of CDAD correlated with the number of doses of PPI per admission (ρ = 0.891, P &lt; .001) and with the number of doses of antimicrobials per admission (ρ = 0.806, .005 &gt; P &gt; .001). The correlation of CDAD incidence with high-risk and low-risk antimicrobials was significant for both groups (ρ = 0.624, .05 &gt; P &gt; .025, and ρ = 0.881, P &lt; .001, respectively). The correlation of oral and intravenous PPI dosing and CDAD incidence was significant for both (ρ=0.903, P &lt; .001, and ρ=0.806, .005 &gt; P &gt; .001, respectively). Multiple regression analysis with both antimicrobials and PPIs as predictors of CDAD was statistically significant ( R2 = 0.75, P = .0082). Conclusion The incidence of CDAD is correlated with PPI use. Antimicrobials are a well-established risk factor for CDAD, and our study reinforces this. Prescribers should consider limiting risk of CDAD by the judicious use of PPIs.

Canaries in a Coal Mine: A Case Report of Increased Incidence of Clostridium Difficile in a Pediatric Oncology Patient Population

The Golisano Children's Hospital (GCH) at Strong Memorial Hospital at the University of Rochester in Rochester NY provides tertiary care to over 3,000 patients each year, including 165 pediatric oncology patients each year. In July 2011, the incidence of C. difficile infection (CDI) in the GCH rose from an average monthly rate of 9.3/1,000 pt days (n=3) to 25.7/1,000 pt days (n=9).

Predictors of severe outcomes associated with Clostridium difficile infection in patients with inflammatory bowel disease

The increasing incidence of Clostridium difficile (C. difficile) infection (CDI) among patients with inflammatory bowel disease is well recognised. However, most studies have focused on demonstrating that CDI is associated with adverse outcomes in IBD patients. Few have attempted to identify predictors of severe outcomes associated with CDI among IBD patients. To identify clinical and laboratory factors that predict severe outcomes associated with CDI in IBD patients. From a multi-institution EMR database, we identified all hospitalised patients with at least one diagnosis code for C. difficile from among those with a diagnosis of Crohn's disease or ulcerative colitis. Our primary outcome was time to total colectomy or death with follow-up censored at 180 days after CDI. Cox proportional hazards models were used to identify predictors of the primary outcome from among demographic, disease-related, laboratory and medication variables. A total of 294 patients with CDI-IBD were included in our study. Of these, 58 patients (20%) met our primary outcome (45 deaths, 13 colectomy) at a median of 31 days. On multivariate analysis, serum albumin <3 g/dL (HR 5.75, 95% CI 1.34-24.56), haemoglobin below 9 g/dL (HR 5.29, 95% CI 1.58-17.69) and creatinine above 1.5 mg/dL (HR 1.98, 95% CI 1.04-3.79) were independent predictors of our primary outcome. Examining laboratory parameters as continuous variables or shortening our primary outcome to include events within 90 days yielded similar results. Serum albumin below 3 g/dL, haemoglobin below 9 g/dL and serum creatinine above 1.5 mg/dL were independent predictors of severe outcomes in hospitalised IBD patients with Clostridium difficile infection.

Changing incidence and clinical manifestations of Clostridium difficile-associated diarrhea detected by combination of glutamate dehydrogenase and toxin assay in Northern Taiwan

The incidence of Clostridium difficile-associated diarrhea (CDAD) is increasing worldwide. Spread of an epidemic hypervirulent strain in southern Taiwan was associated with poor outcome. This prospective study evaluates the incidence and clinical manifestation of CDAD following a hospital-wide hand hygiene promotion program in a 2,200-bed teaching hospital in northern Taiwan. From June 1, 2010 to October 31, 2010, a predefined protocol was used to actively survey CDAD at 11 high-risk units. Stool samples of patients with antibiotic-associated diarrhea (AAD) were submitted for stool culture and toxin A/B assay using a combined enzyme immunoassay. CDAD was diagnosed by a positive toxin assay. The incidence of CDAD was 0.45/1000 patient-days and was highest in medical intensive care units (7.9/1000 patient-days), followed by hemato-oncology wards, and infectious disease wards. Occurrence of CDAD was associated with ≥3 stool pus cells per high power field (p=0.018), prior use of metronidazole (p=0.029), high usage of beta-lactamase stable penicillins (p=0.046), and anaerobe-active antibiotics (p=0.029). No attributable mortality was found. The incidence of CDAD was lower than that previously observed (1.0/1000 patient-days in 2003, p<0.001). This study showed a lower incidence of CDAD and absence of attributable mortality. The impact of hand hygiene promotion and other infection control measures on decreasing incidence of CDAD warrants further elucidation.

Accuracy of ICD9 and ICD 10 Codes for Clostridium difficile Among Ulcerative Colitis Patients

Purpose: The incidence of Clostridium difficile (C. difficile) infections has increased among ulcerative colitis (UC) patients. Researchers have commonly used administrative databases to study associations between C. difficile infection and UC; however, the validity of diagnostic code for C. difficile in UC patients is unknown. The aims of this study were to: 1) evaluate the accuracy of administrative codes for C. difficile infections in UC; and 2) assess whether the frequency of testing for C. difficile and C. difficile diagnosis has changed over time. Methods: Population based surveillance was conducted in the Calgary Health Zone between January 1, 2004 and December 31, 2009 using the Discharge Abstract Database to identify adults (≥ 18 years) admitted to the hospital for UC flare-up (n=583). These patients were concurrently searched for ICD-9 (008.45) or ICD-10 (A04.7) codes for C. difficile diagnosis. In addition, the Calgary Laboratory Services (CLS) provided the results of all C. difficile toxin tests ordered for UC patients admitted to the hospital between 2004 and 2009 (n=389). Only tests performed during hospital admission and up to 7 days prior to admission to hospital were included in the analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) with 95% CIs were calculated by comparing ICD9/10 codes for C. difficile in the Discharge Abstract Database with results of CLS stool C. difficile toxin testing. Subsequently, stool toxin tests were used to define the proportion of UC patients who were tested for C. difficile who had a positive result. Joint point regression analysis was used to test for temporal trends in C. difficile testing and positive C. difficile 2004-2009. Results: Over a 6-year period, 288 (74%) UC patients admitted to hospital were tested for C. difficile and 8 (2.8%) were positive. The sensitivity, specificity, PPV and NPV of administrative data in identifying C. difficile infection in hospital was 88% [47%-100%], 100% [98%-100%], 88% [47%-100%] and 100% [98%-100%], respectively. The proportion of UC patients who were tested for C. difficile and who had a positive result remained stable between 2004 and 2009 (Figure 1). Conclusion: Laboratory proven C. difficile infection occurred in 3% of hospitalized UC patients and administrative data accurately identified this. Approximately one quarter of hospitalized UC patients were not tested for C. difficile in hospital or 7 days before hospitalization, which has important implications for clinical care and quality assurance.

Fidaxomicin: first-in-class macrocyclic antibiotic

The incidence of Clostridium difficile has doubled over the past 15 years, and rising mortality rates associated with this infection have followed in its wake. C. difficile infection (CDI) has supplanted methicillin-resistant Staphylococcus aureus as the major cause of nosocomial infection. An insufficient response rate to currently available CDI therapies has prompted the search for new and alternative treatment modalities for this disease. The investigational pipeline includes evaluation of new antimicrobial agents that exhibit good activity against C. difficile without altering normal gut flora, C. difficile toxin-absorbing compounds, and preformed antibodies and vaccines against C. difficile toxin. In two robust clinical trials comparing fidaxomicin to vancomycin in the treatment of CDI, treatment with fidaxomicin demonstrated a superior global cure (cure without recurrence) rate compared with the current gold standard, vancomycin. Fidaxomicin, the first of a new class of macrocyclic antimicrobial agents, represents an advance in the management of CDI.

Impact of Clostridium difficile-associated disease in a regional hospital

For the recent years, our institution had an incidence of Clostridium difficile associated disease (CDAD) higher than the provincial rate. This study reviewed the burden of CDAD in our hospital.

Clinical approach to severe Clostridium difficile infection: Update for the hospital practitioner

The rising incidence of Clostridium difficile ( C. difficile) infection or CDI is now a problem of pandemic proportions. The NAP1 hypervirulent strain of C. difficile is responsible for a majority of recent epidemics and the widespread use of fluoroquinolone antibiotics may have facilitated the selective proliferation of this strain. The NAP1 strain also is more likely to cause severe and fulminant colitis characterized by marked leukocytosis, renal failure, hemodynamic instability, and toxic megacolon. No single test suffices to diagnose severe CDI, instead; the clinician must rely on a combination of clinical acumen, laboratory testing, and radiologic and endoscopic modalities. Although oral vancomycin and metronidazole are considered standard therapies in the medical management of CDI, recently it has been demonstrated that vancomycin is the more effective antibiotic in cases of severe disease. Moreover, early surgical consultation is necessary in patients who do not respond to medical therapy or who demonstrate rising white blood cell counts or hemodynamic instability indicative of fulminant colitis. Subtotal colectomy with end ileostomy is the procedure of choice for fulminant colitis. When applied to select patients in a judicious and timely fashion, surgery can be a life-saving intervention. In addition to these therapeutic approaches, several investigational treatments including novel antibiotics, fecal bacteriotherapy and immunotherapy have shown promise in the care of patients with severe CDI.

Clostridium Difficile–Associated Diarrhea in a Tertiary Care Medical Center

This retrospective, case-control study aimed to identify variables associated with the incidence of Clostridium difficile–associated diarrhea (CDAD) in acute care facilities and to specifically identify the relationship of fluoroquinolones and acid suppressive agents in the development of CDAD. Seventy-one symptomatic patients positive for C. difficile toxin A or B hospitalized for at least 72 hours were compared with 142 control patients hospitalized for at least 72 hours who were not positive for C. difficile toxin A or B. Two controls were matched to one case patient for age within 5 years, unit of admission, and date of admission. The mean ages for cases and controls were 63.5 and 62.7 years, respectively. After adjusting for two confounding variables—hospital stay within 3 months and Charlson Comorbidity Index—conditional multiple logistic regression identified six risk factors for development of CDAD: gastrointestinal procedures within 60 days (odds ratio [OR] 9.1, P < 0.013), levofloxacin exposure (OR 8.2, P < 0.033), moxifloxacin exposure (OR 4.1, P < 0.026), imipenem exposure (OR 14.9, P < 0.014), laxative use (OR 20.2, P < 0.0001), and immunosuppressive use (OR 20.7, P < 0.034). The risk of CDAD after exposure to levofloxacin or moxifloxacin was not significantly different. Acid suppressive therapy was not a risk factor for CDAD development.

Factors Predicting Severity in Clostridium difficile Infection

Purpose: The incidence of Clostridium difficile Associated Diarrhea (CDAD) continues to rise; especially among inpatient, elderly, institutionalized, & debilitated populations. RUWA scoring system, a model developed to predict severity of CDAD, has been an important stepping stone in predicting severity. However, to date, no study has established a sufficiently accurate model applicable in community hospitals. The aim of the study is to identify factors predictive of severity & mortality in CDAD in community hospitals. Methods: Charts of 499 patients in 3 community hospitals, diagnosed with CDAD from Jan 2007 to Dec 2008 were retrospectively reviewed. Data was collected on patient factors such as chronic heart, lung, and kidney disease, diabetes, demographics, institutionalization, albumin, creatinine, PMNs, and WBCs. Severe disease was defined as pancolitis or megacolon on CT, mortality, and need for ICU admission. Results: The patients had a mean age of 72.5 years with a standard deviation of 16.42 years. In the study group, 62.12 were female, 50.5% were institutionalized, 72.7% had chronic disease, 11.62% required ICU care, and inpatient mortality was 11.42%. Low albumin (95.5% died vs. 58.3% lived, p=<0.001) and elevated PMNs (89.1% vs. 76.1% p=0.059) were more frequent in CDAD patients who died. Chronic disease was significantly more prevalent in those with CDAD who died during hospitalization compared with those who lived (86% vs. 71%, p=0.017). In our preliminary analysis, we did not find a significant association between institutionalization and CDAD mortality. Chronic disease was less frequent among patients who developed pancolitis or megacolon on CT compared with those who did not have such CT findings (63.7% vs. 75.1%, p=.025). Neither age nor albumin level were significantly related to CT finding of pancolitis or megacolon. Age, albumin, chronic disease, creatinine & PMNs were not significantly associated with the need for ICU admission. History of IBD, surgery, CDAD & subtotal colectomy were not analyzed due to their infrequent occurrence in our population. Conclusion: Mortality of hospitalized patients with C. difficile appear to be related to chronic disease, low albumin, and elevated PMNs. Whereas, institutionalization, age, gender, creatinine, and CT findings are not related to severity. Our study along with the RUWA model form the basis for a future prospective, multicenter trial which would help develop a reproducible model for predicting severity in CDAD in tertiary and community hospitals.

Recurrence rate of clostridium difficile infection in hospitalized pediatric patients with inflammatory bowel disease

The incidence and associated morbidity of Clostridium difficile (CD) infection has been increasing at an alarming rate in North America. Clostridium difficile-associated diarrhea (CDAD) is the leading cause of nosocomial diarrhea in the USA. Patients with CDAD have longer average hospital admissions and additional hospital costs. Evidence has demonstrated that patients with inflammatory bowel disease (IBD) have a higher incidence of CD in comparison to the general population. The aim of this study was to compare the rate of recurrence of CD in hospitalized pediatric patients with IBD compared to hospitalized controls. The secondary aim was to evaluate whether infection with CD resulted in a more severe disease course of IBD. This was a nested case control retrospective study of hospitalized pediatric patients. Diagnosis of CD was confirmed with stool Toxin A and B analysis. The following data were obtained from the medical records: demographic information, classification of IBD including location of disease, IBD therapy, and prior surgeries. In addition, prior hospital admissions within 1 year and antibiotic exposure were recorded. The same information was recorded following CD infection. Cases were patients with IBD and CD; two control populations were also studied: patients with CD but without IBD, and patients with IBD but without CD. For aim 1, a total of 111 eligible patients with IBD and CD infection and 77 eligible control patients with CD infection were included. The rate of recurrence of CD in the IBD population was 34% compared to 7.5% in the control population (P < 0.0001). In evaluating the effect of CD infection on IBD disease severity, we compared the 111 IBD patients with CD to a second control population of 127 IBD patients without CD. 57% of IBD-CD patients were readmitted with an exacerbation of disease within 6 months of infection with CD and 67% required escalation of therapy following CD infection, compared to 30% of IBD patients without CD (P < 0.001). Of the patients with IBD and CD, 44% of the cases were new-onset IBD, 63% were on immunosuppression therapy, and 33% were on gastric acid suppression prior to infection. In comparing the IBD-CD and control CD populations, there was no significant difference in antibiotic exposure: 33% of IBD patients and 26% of control patients were on antibiotics (P < 0.2). With regard to prior hospitalization, 10% of patients with IBD were hospitalized in the 30 days prior to infection in comparison to 27% of the control CD patients (P < 0.002). CD infection in patients with IBD results in a higher rate of recurrence and is associated with higher morbidity than the general population. Patients with IBD often required hospitalization and escalation of therapy following infection with CD, suggesting that CD resulted in increased severity of IBD disease. In addition, IBD patients were more likely develop community-acquired CD, while the control patients developed nosocomial infections, indicating a higher susceptibility to CD infection in patients with IBD.