Nosocomial Clostridium Difficile Infection Research Articles

Prescribed probiotic usage to prevent Clostridioides difficile infection among older patients receiving antibiotics: A retrospective cohort study

ObjectivesClostridioides difficile infection (CDI) is a leading cause of antimicrobial-associated colitis and is a global clinical concern. Probiotics are considered a CDI-preventive measure; however, highly inconsistent data have been previously reported. Thus, we evaluated the CDI-preventive effect of prescribed probiotics in high-risk older patients receiving antibiotics. MethodsOlder patients (aged ≥65 years) admitted to the emergency department who received antibiotics between 2014 and 2017 were enrolled in this single-center retrospective cohort study. Propensity score-matched analysis was used to compare the CDI incidence in patients who took the prescribed probiotics within 2 days of receiving antibiotics for at least 7 days with those who did not. The rates of severe CDI and associated hospital mortality were also evaluated. ResultsAmong 6148 eligible patients, 221 were included in the prescribed probiotic group. A propensity score-matched (221 matched pairs) well-balanced for patient characteristics was obtained. The incidence of primary nosocomial CDI did not differ significantly between the prescribed and non-prescribed probiotic groups (0% [0/221] vs. 1.0% [2/221], p = 0.156). Of the 6148 eligible patients, 0.5% (30/6148) developed CDI, with a severe CDI rate of 33.3% (10/30). Furthermore, no CDI-associated in-hospital mortality was observed in the study cohort. ConclusionsThe evidence from this study does not support recommendations for the routine use of prescribed probiotics to prevent primary CDI in older patients receiving antibiotics in situations where the CDI is infrequent.

Costs Associated with the Treatment of Clostridioides Difficile Infections.

Background: Clostridioides difficile, as the main cause of infectious diarrhoea in hospitalised patients, is a considerable challenge for medical personnel (hospital environment) who have direct contact with the patient, as well as being of interest to public health specialists. Financial issues related to the occurrence of the above-mentioned micro-organism are being increasingly raised. Due to the scale of the phenomenon, we are beginning to pay attention to the significant system costs caused by the diagnosis and treatment of CDI infection and its complications. Studies indicate that the nosocomial infection of C. difficile complicates hospitalisation, by increasing the cost by more than half and extending patient’s stay by an average of 3.6 days. Material and methods: The aim of this study was to attempt to calculate the estimated costs associated with the prolonged hospitalisation of patients with nosocomial CDI infection, using the example of a hospital in Lodz. A total of 53 completed hospitalisations of patients treated in the period of January–August 2018 were analysed, during which hospital Clostridioides difficile infection was identified. For the purposes of this study, statistical data collected in the hospital’s IT system were also analysed, covering 44,868 hospitalisations in the Jan–Aug 2018 period, during which no hospital infection occurred. They was a control group, in which the analysed cases were compared. The obtained data in the study determined how long each patient with Clostridioides difficile infection stayed in the hospital (from the moment infection was diagnosed until the day of hospital discharge), and which diagnosis related groups (DRG) (according to National Health Fund guidelines) were assigned. The average length of patient stay without infection within a given DRG group in each hospital ward was also determined. The collected materials became the initial point for the final analysis of hospital costs and the length of hospital stay caused by Clostridioides difficile infection. Results: Clostridioides difficile infection extended the hospital stay by an average of almost 12 days. The average cost of prolonged hospitalisation due to CDI infection (according to the average cost per person-day) was about PLN 7148 (1664 EUR), which gave a total value of about PLN 378,860.6 (88,240.5 EUR) in the examined period. At the same time, the average expenditure from the National Health Fund for hospitalisation due to CDI infections increased by about PLN 6627 (1542.8 EUR), which in the analysed period translated into over PLN 351,232.0 (81,505.5 EUR) (according to settlements with the National Health Fund). The outcome indicates that there is a clear relation between CDI and the anticipated length of hospitalisation of patients without an infection.

Anastomotic Leak is Increased With Clostridium difficile Infection After Colectomy: Machine Learning-Augmented Propensity Score Modified Analysis of 46 735 Patients.

Clostridium difficile infection (CDI) is now the most common cause of healthcare-associated infections, with increasing prevalence, severity, and mortality of nosocomial and community-acquired CDI which makes up approximately one third of all CDI. There are also increased rates of asymptomatic colonization particularly in high-risk patients. C difficile is a known collagenase-producing bacteria which may contribute to anastomotic leak (AL). Machine learning-augmented multivariable regression and propensity score (PS)-modified analysis was performed in this nationally representative case-control study of CDI and anastomotic leak, mortality, and length of stay for colectomy patients using the ACS-NSQIP database. Among 46735 colectomy patients meeting study criteria, mean age was 61.7years (SD 14.38), 52.2% were woman, 72.5% were Caucasian, 1.5% developed CDI, 3.1% developed anastomotic leak, and 1.6% died. In machine learning (backward propagation neural network)-augmented multivariable regression, CDI significantly increases anastomotic leak (OR 2.39, 95% CI 1.70-3.36; P < .001), which is similar to the neural network results. Having CDI increased the independent likelihood of anastomotic leak by 3.8% to 6.8% overall, and in dose-dependent fashion with increasing ASA class to 4.3%, 5.7%, 7.6%, and 10.0%, respectively, for ASA class I to IV. In doubly robust augmented inverse probability weighted PS analysis, CDI significantly increases the likelihood of AL by 4.58% (95% CI 2.10-7.06; P < .001). This is the first known nationally representative study on CDI and AL, mortality, and length of stay among colectomy patients. Using advanced machine learning and PS analysis, we provide evidence that suggests CDI increases AL in a dose-dependent manner with increasing ASA Class.

Assessing risk factors, mortality, and healthcare utilization associated with Clostridioides difficile infection in four Latin American countries

BackgroundClostridioides difficile infection (CDI) is the most common cause of healthcare-associated infections in Western countries. Risk factors, mortality, and healthcare utilization for CDI in Latin America are poorly understood. This study assessed risk factors and burden associated with nosocomial CDI in four Latin American countries. MethodsThis retrospective, case-control study used databases and medical records from 8 hospitals in Argentina, Brazil, Chile, and Mexico to identify nosocomial CDI cases from 2014 − 2017. Cases were patients aged ≥18 years with diarrhea and a positive CDI test ≥72 h after hospital admission. Two controls (without diarrhea; length of hospital stay [LOS] ≥3 days; admitted ±14 days from case patient; shared same ward) were matched to each case. CDI-associated risk factors were assessed by univariate and multivariable analyses. CDI burden (LOS, in-hospital mortality) was compared between cases and controls. ResultsThe study included 481 cases and 962 controls. Mean age and sex were similar between cases and controls, but mean Charlson comorbidity index (4.3 vs 3.6; p < 0.001) and recent hospital admission (35.3% vs 18.8%; p < 0.001) were higher among cases. By multivariable analyses, CDI risk was associated with prior hospital admission within 3 months (odds ratio [OR], 2.08; 95% CI: 1.45, 2.97), recent antibiotic use (ie, carbapenem; OR, 2.85; 95% CI: 1.75, 4.64), acid suppressive therapy use (OR, 1.71; 95% CI: 1.14, 2.58), and medical conditions (ie, renal disease; OR, 1.48; 95% CI: 1.19, 1.85). In-hospital mortality rate (18.7% vs 6.9%; p < 0.001) and mean overall LOS (33.5 vs 18.8 days; p < 0.001) were higher and longer, respectively, in cases versus controls. ConclusionAntibiotic exposure, preexisting medical conditions, and recent hospital admission were major risk factors for CDI in Argentina, Brazil, Chile, and Mexico. CDI was associated with increased in-hospital risk of death and longer LOS. These findings are consistent with published literature in Western countries.

Molecular Characterization and Diagnosis of Nosocomial Clostridium difficile Infection in Hospitalized Patients

Background: Toxigenic Clostridium difficile is one of the prevalent diarrheagenic pathogens in hospitalized patients. Objectives: The study assessed the ability of three diagnostic methods in identifying C. difficile strains. The genotyping of the isolates was done, as well. Methods: Stool samples were subjected to three different diagnostic methods including direct stool culture, glutamate dehydroge-nase enzyme immunoassay (GDH-EIA), and direct stool PCR for the detection of the tcdA and tcdB genes. The sensitivity and specificity of the tests were evaluated. The genotyping was done by the PFGE method. Results: Of 120 samples, 20 (16) were positive for C. difficile based on PCR, while 15 (12.5) and 12 (10) were positive according to GDH-EIA and direct stool culture. Among patients with C. difficile-associated diseases (CDAD), 11 (61) were more than 65-years-old. The specificity of PCR, GDH-EIA, and direct culture was almost similar and equal to 100, but their sensitivity was 90, 70, and 60, respectively. The positive predictive value (PPV) was lower for GDH-EIA than for the other two methods, and the highest negative predictive value (NPV) was related to the PCR method. The results showed a high similarity between the isolates, and only were three pulsotypes differentiated among the isolates. Conclusions: The specificity and sensitivity of the direct stool PCR method were higher than those of the other two methods. Al-though PCR inhibitors may reduce its ability for the correct diagnosis of negative samples, it seems to be a reliable method for the detection of C. difficile infection. The weakness of the GDH-EIA method was its lower PPV, which can cause false-positive results. Toxin patterns and pulsotypes of C. difficile isolates revealed a high similarity between the strains isolated from the same units. © 2020, Author(s).

Effectiveness and cost-effectiveness of a Clostridium difficile vaccine candidate in a hospital setting

Toxoid vaccines against Clostridium difficile infections (CDI) appear promising in reducing the risk of developing toxin-mediated symptoms. We sought to evaluate the effectiveness and cost-effectiveness of a vaccine candidate in a hospital setting. We developed an agent-based simulation model of nosocomial CDI in a 300-bed hospital. Targeting high-risk patients for vaccination, we estimated the reduction of symptomatic CDI. Using the net reduction of CDI-associated isolation days, we evaluated the vaccine’s cost-effectiveness from a healthcare provider perspective over a 2-year period with an average monthly incidence of 5 cases per 10,000 patient-days pre-vaccination.Assuming a vaccine efficacy in the range 60–90%, vaccinating 40% of high-risk patients pre-admission reduced symptomatic CDI by 16.6% (95% CI: 15.2, 17.9). When the vaccine coverage increased to 80%, the reduction of symptomatic CDI was 34.6% (95% CI: 33.7, 35.9). For a willingness to pay (WTP) of CDN$1000 (corresponding to the average costs of case isolation per day), vaccine was cost-effective for vaccination costs per individual (VCPI) up to CDN$111 in the scenario of 40% vaccine coverage. With the same WTP, vaccine was cost-effective for VCPI up to CDN$121 when the vaccine coverage increased to 80%. A significant portion (~80%) of hospital colonization is caused by environmental transmission of C. difficile, which markedly reduced the effectiveness of vaccine below its assumed efficacy. However, due to the number of CDI-associated isolation days averted, vaccination of high-risk patients can be cost-effective depending on the WTP and the VCPI.

C. difficile vaccine cost effective for prevention of nosocomial CDI

C. difficile vaccine cost effective for prevention of nosocomial CDI

Incidence of Clostridium difficile Infection After Sepsis Protocol Antibiotics.

IntroductionThe management of sepsis includes the prompt administration of intravenous antibiotics. There is concern that sepsis treatment protocols may be inaccurate in identifying true sepsis and exposing patients to potentially harmful antibiotics, sometimes unnecessarily. This study was designed to investigate those concerns by focusing on in-hospital Clostridium difficile infection (CDI), which is a known complication of exposure to antibiotics.MethodsOur emergency department (ED) recently implemented a protocol to help combat sepsis and increase compliance with the 2017 Sepsis CMS Core Measures (SEP-1) guidelines. In this single-center, retrospective cohort analysis we queried the electronic health record to gather data on nosocomial CDI and antibiotics prescribed over a five-year period to analyze the effect of the introduction of a sepsis protocol order set. The primary goal of this study was to measure the hospital-wide CDI rate for three years prior to implementation of the sepsis bundle, and then compare this to the hospital-wide CDI rate two years post-implementation. As a secondary outcome, we compared the number of antibiotics prescribed in the ED 12 months prior to administration of the sepsis protocol vs 12 months post-initiation.ResultsOver the course of five years, the hospital averaged 9.4 nosocomial CDIs per 10,000 patient hours. Prior to implementation of the sepsis bundle, the average CDI rate was 11.6 (±1.11, 95%) and after implementation the average rate dropped to 6.2 (±1.27, 95%, p<0.01). The mean number of antibiotics ordered per patient visit was 0.33 (±0.015, 95%) prior to bundle activation, and, following sepsis bundle activation, the rate was 0.38 (±0.019, 95%, p<0.01). This accounted for 38% of all ED patient visits receiving antibiotics, a 5% increase after the sepsis bundle was introduced.ConclusionIn this study, we found that CDI infections declined after implementation of a sepsis bundle. There was, however an increase in the number of patients being exposed to antibiotics after this hospital policy change. There are more risks than just CDI with antibiotic exposure, and these were not measured in this study. Subsequent studies should focus on the ongoing effects of timed, protocolized care and the associated risks.

2417. Feasibility and Safety of Using a Probiotic Comprised of Lactobacillus acidophilus CL1285, L. casei LBC80R and L. rhamnosus CLR2 for C. difficile Infection Prevention Among Antibiotic Users: 15-Years of Prospective Results from a Single-Center

BackgroundHospitals use multiple concurrent prevention strategies to curb nosocomial C. difficile infection, but there are limited data on the long-term feasibility or safety of using a probiotic. Pierre-Le Gardeur Hospital, Québec, has been administering a probiotic comprised of Lactobacillus acidophilus CL1285, L. casei LBC80R and L. rhamnosus CLR2 since 2004 with documented results through March 31, 2014. Here we present an update for the past 5 years.MethodsSeveral nosocomial infection prevention practices were running concurrently at the hospital. Adult inpatients treated with antibiotics from April 1, 2014 to March 31, 2019 were eligible to receive the probiotic. The hospital pharmacy ensured that each patient took the probiotic capsules (Bio-K+® 50 Billion) daily from the initiation of antibiotic use. Confirmed nosocomial cases of C. difficile infection were recorded and reported to the provincial public health agency. The rate of nosocomial CDI for this hospital was compared with other non-University affiliated hospitals in the health region with more than 110 beds and fewer than 45% of patients age 65 and older, and, to all other hospitals in the health system.ResultsCumulatively over the past 15 years, more than sixty thousand antibiotic-treated adult inpatients took the probiotic daily during antibiotic use. Among 13 comparable hospitals, Pierre-Le Gardeur Hospital had the lowest rate of nosocomial CDI in 2014–2015, 2015–2016, 2016–2017, 2017–2018 and on average had the lowest rate for 2013–2018 (1.1 CDI cases per 10,000 patient-days). Compared with all hospitals in the Province of Quebec health system, N = 95, the hospital had the lowest nosocomial CDI rate on average for 2013–2018. No cases of Lactobacillus bacteremia were detected.ConclusionThe overall infection prevention strategy has been highly effective, resulting in a consistently low rate of nosocomial CDI. We found that it is feasible to administer this probiotic to antibiotic-treated inpatients with few restrictions. No Lactobacillus infections were observed from any of the three strains of bacteria for this probiotic when given to more than sixty thousand adult inpatients. Disclosures All authors: No reported disclosures.

2345. Reduction in Testing and Change in Testing Algorithm Associated with Decrease in Number of Nosocomial Clostridium difficile Infections

BackgroundPrevious data at our facility indicated 37% of patients with Clostridium difficile infection (CDI) were receiving at least one laxative at the time of testing, suggesting the possibility of false-positive results. Nucleic acid amplification testing (NAAT) does not distinguish between colonization and infection with C. difficile. We implemented two interventions to address these issues and evaluated our rates of nosocomial CDI before and after these changes.MethodsThis was a retrospective study of all positive test results for adult patients with nosocomial C. difficile from October 1, 2017 through March 31, 2019 at Vidant Medical Center, a 911-bed hospital. In June, 2018, we implemented a best practice advisory (BPA) in our electronic health record to recommend against testing for CDI in patients receiving laxatives. We reviewed the number of C. difficile tests ordered before and after initiating the BPA. In December, 2018, we removed NAAT and replaced it with a cell cytotoxicity assay (CCA) for specimens that were enzyme immunoassay (EIA) negative and glutamate dehydrogenase (GDH) positive. Antimicrobial use was measured in days of therapy (DOT) per 10,000 patient-days (PD). Mann–Whitney U test was used for continuous variables. Linear regression was used to monitor antimicrobial use.ResultsThe number of C. difficile tests ordered per month decreased 19.5% after implementing the BPA (P < 0.0001). There was a 44% reduction in the number of EIA+/GDH+ specimens per month after the BPA intervention (P = 0.003). Following substitution of CCA for NAAT for EIA-/GDH+ specimens, there was a 61% reduction in the rate of nosocomial CDI (8.6 cases/10,000 PD to 3.3 cases/10,000 PD; P = 0.005). Total antimicrobial use was unchanged over the course of the study (673 to 677 DOT/10,000 PD). Carbapenem use decreased 56% (P = 0.009); cefepime use increased 85%(p = 0.002); quinolone and clindamycin use were unchanged.ConclusionLaxative use in hospitalized patients is common and likely contributes to a false elevation in the CDI rate by identifying carriers in addition to those who have true infection. Implementing a BPA to reduce inappropriate testing and changing our testing algorithm for Clostridium difficile by substituting CCA for NAAT has resulted in a lower rate of nosocomial CDI. Disclosures All authors: No reported disclosures.

2671. Outcomes of Clostridium difficile Infection in Solid-Organ Transplant Patients: Nationwide Inpatient Sample 2015–2016

Background Clostridium difficile infection (CDI) is a leading cause of morbidity and mortality in a hospitalized patient. The incidence and severity of nosocomial CDI have increased significantly since the year 2000. Solid-organ transplant recipients (SOT) are at high risk for CDI for multiple reasons including impaired defense mechanisms from immunosuppression, perioperative antibiotic use, and organ failure. For the past decade, there has been the advance modality of diagnosis and treatments for CDI including early detection of toxin, novel antibiotics, and fecal microbiota transplantation. With the innovative measurements and the effort of antibiotic stewardship, the recent study show improvement of mortality in hospitalized CDI; however, there is still lack of such evidence among SOT patients. Therefore, it would be beneficial to scrutinize the prevalence and outcomes of CDI among SOTs with the most current available nationwide database.MethodsOur study utilized the 2015 and 2016 National Inpatient Sample (NIS). It is the largest publicly available all-payer inpatient healthcare database in the United States, yielding national estimates of hospital inpatient stays. Patients with history or undergoing SOT transplant procedure who were hospitalized in 2015 and 2016 NIS database were included in our study. We included heart, lung, liver, intestinal, kidney, pancreas, or at least one of these organs transplanted in our definiton of SOT. History of organ tranplants and CDI were extracted by using ICD-9-CM and ICD-10-CM from discharged diagnosis. Baseline characteristic include age, gender, race, median household income were collected. Confounding includes comorbidities which were calculated into charlson comorbidity index (CCI) and discharge diagnosis of pneumonia and urinary tract infection. Primary outcomes include in-patient mortality, hospital length of stay and total hospital charges. Secondary outcomes include transplant failure or rejection, colectomy and disposition of patients. Multivariable logistic regression was used for the adjusted analysis of the primary and secondary outcomes include all confounders and significant covariates. All reported CIs were two-sided 95% intervals, and tests were done at the two-sided 5% significance level. Stata v14.2 (Stata Corp, College Station, Texas) was utilized for all analyses.ResultsA total of 107,461 discharges of SOTs in 2015–2016 NIS database were included in our study. The mean age was 53 years (SD 17) and 45,666 (42%) were female. History of kidney transplant was found to be the most common (55%) and history of liver tranplants was the second most common (19%) among our population.The incidence of CDI was 3,626 (3.37%) among SOTs. Factors associated with CDI include age (4% increasing of odds for 10-year increment in age), female (OR 1.2; 95% CI 1.16–1.34), history of heart transplant (OR 1.28; 95% CI 1.11–1.48), kidney transplant (OR 0.98; 95% CI 0.82–0.97), UTI (OR 1.65; 95% CI 1.50–1.81) and pneumonia (OR 1.24;; 95% CI 1.122- 1.38). CDI associated with higher inpatient mortality (OR 1.85, 95% CI 1.56–2.20, P < 0.01), longer length of hospital stay (mean difference 5.07 days, 95% CI 4.43–5.71, P < 0.01) and higher total hospital charges (mean difference 43,958 dollars, P < 0.01). Furthermore, SOTs with CDI had higher risk of transplant complication (OR1.67, 95% CI 1.50–1.87, P < 001) and increase risk of colectomy (OR 2.36, 95% CI 1.50–3.72). Those who had CDI were less likely to be discharged home when compare to non-CDI (OR 0.53, 95% CI 0.49–0.58, P < 0.01).ConclusionOur study found that CDI associated with significant overall worse outcomes among hospitalized solid-organ transplant patients. Multicenter prospective study is considered as a future direction to evaluate the impact to healthcare. Despite the improvement of overall mortality of CDI in general population in the United States from prior study, CDI in SOTs remains problematic. More attention is needed in this particular field. Disclosures All authors: No reported disclosures.

135 Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection in Patients Above 75 Years of Age: A Tertiary Center Experience

INTRODUCTION: Fecal microbiota transplantation (FMT) is established as an effective treatment for recurrent Clostridioides (formerly Clostridium) difficile infection (CDI). Incidence and mortality from CDI are significantly higher in the elderly population (CDI is 10 times more common and 92% of CDI-related deaths occur in the elderly). Risk of cardiopulmonary complications from sedation prior to colonoscopy is increased in the elderly. Efficacy and safety of FMT via colonoscopy in the elderly are unknown. METHODS: A retrospective study comparing patients ≥75 years, and patients &lt; 75 years who had FMT at Sanford Medical Center, Sioux Falls, SD, between 2013–2018. All patients underwent FMT via colonoscopy. Antibiotics prior to FMT, donor screening, preparation and delivery of FMT, and post-procedural follow up were based on a standardized protocol in our institution. Data on baseline characteristics, co-morbidities, antibiotics-associated with CDI, safety, and success rate of treatment (defined by resolution of symptoms and absence of CDI recurrence at 8 and 52 weeks) were collected. RESULTS: Of 59 patients, 17 (28.8%) were ≥75 years with a mean age of 84.4 years, and 42 (71.2%) were &lt;75 years and a mean age of 46.4 years. Baseline characteristics of both groups are described in Table 1. Number of CDI before FMT, history of severe CDI, nosocomial CDI were similar. No fulminant CDI was reported in our study. In ≥75 years vs. &lt;75 years, serum albumin was lower (3.4 vs 4 g/dl, P &lt; 0.002) and hypertension was more common (52.9 vs 23.8%, P = 0.03). 80% of our study population had a history of antibiotics exposure prior to CDI, but there was no statistically significant difference between groups. Of antibiotics-associated with CDI, penicillins were more likely to be reported in ≥75 vs. &lt;75 years (38.1 vs 5.9%, P = 0.014). Cephalosporins, macrolides, fluoroquinolones, and clindamycin were similar in both groups. Prior to FMT, both groups were treated similarly with vancomycin with or without taper, oral or intravenous metronidazole, or fidaxomicin. No major complications related to anesthesia or FMT via colonoscopy or deaths attributed to FMT were reported in our study. The success rates at 8 and 52 weeks in both groups were similar (76.5 vs. 83.3%, and 76.5 vs. 71.4%, respectively). CONCLUSION: Despite the increased risk of CDI and colonoscopy in the elderly population, success rate and safety of FMT appears to be equivalent between elderly and non-elderly. Prospective studies with larger sample size are needed.

Clostridium Difficile: Reducing Infections Using an Evidence-Based Practice Initiative.

Nosocomial Clostridium difficile (C. difficile) infections are adverse incidents that affect immunocompromised hospitalized patients. High-touch surface areas within the patient's environment are frequently overlooked and are a source of microscopic bacterial transmission. This article examines whether the use of a standardized protocol for cleaning high-touch surface areas would reduce the incidence of hospital-acquired C. difficile infection. The initiative targeted five high-touch surfaces, and nurses were educated about these findings. Baseline data on the C. difficile infection rate was collected from four specialty medical-surgical oncology units. A pilot period of the Five by Five initiative evaluated C. difficile infection rates after staff cleaning of these high-touch surfaces. This initiative accounted for a statistically significant reduction in C. difficile infections. The use of a standardized cleaning initiative was effective in reducing C. difficile infections. Nursing staff perceived that the education was easy to remember and supported efficient implementation.

Clostridium difficile intervention timelines for diagnosis, isolation, and treatment

Developing timelines of nosocomial Clostridium difficile infection (CDI) is critical to improving control and preventive measures. The objective of this study was to provide data-driven estimates of CDI timelines of diagnosis, isolation, and treatment in a hospital setting. We obtained data for all CDI inpatients with symptoms onset occurring between January 1, 2013, and December 30, 2017, from St Joseph's Healthcare in Hamilton, Canada. We analyzed full empirical distributions of timelines associated with the diagnosis, isolation, and treatment of CDI. A total of 683 inpatients with CDI symptoms were recorded, of which 243 cases were identified as health care-associated infection (HAI). The mean time intervals between the onset of CDI symptoms after admission and the release of laboratory results were 1.2 days and 1.9 days for the HAI and community-associated infection (CAI) patient groups, respectively. The mean time intervals from symptoms onset to the start of isolation were 1.5 days and 2.6 days for the corresponding patient groups. The initiation of treatment within 2 days of symptoms onset reduced the duration of first isolation (P value < .0001); however, the type of initial antibiotic used for CDI treatment was not associated with the duration of isolation. Estimated timelines did not differ (P values > .6) between HAI and CAI patient groups with symptoms onset after admission. These estimates are useful for evaluating the effectiveness of CDI interventions.

Profile of patients admitted in a pulmonology ward and developing Clostridium difficile enterocolitis

Abstract Clostridium difficile is an anaerobic bacterium than can colonise the lower intestine and cause enterocolitis in susceptible patients. Clostridium difficile infection (CDI) is typically a nosocomial infection, favoured by treatment with antibiotics (especially with broad-spectrum drugs), proton pump inhibitors, but also comorbidities, old age and prolonged hospitalisation. Based on the observation that in the past years, the frequency of nosocomial CDI has increased in the Institute of Pulmonology, Bucharest, this retrospective observational study aimed to analyse the characteristics of admitted patients who develop CDI, in order to identify possible particular features and risk factors. Accordingly, medical files from 80 patients admitted from January 2015 to August 2017 were analysed for demographic data, respiratory diagnosis, comorbidities, blood tests, treatments prescribed, time of CDI onset, evolution and outcome. The number of patients studied was 29 in 2015, 16 in 2016 and 35 in 2017, with slight male predominance. Totally, 54 patients (67.5%) had tuberculosis (pulmonary or pleural), 12 had lung cancer, five had respiratory infections, two had chronic obstructive pulmonary disease and seven had other diseases. All patients but nine were receiving antibiotics: tuberculosis drugs, cephalosporins, fluoroquinolones and beta-lactams. About half of the patients received proton pump inhibitors. Most patients had several comorbidities. Mean time since admittance to onset of diarrhoea was 20 days. CDI was treated with metronidazole or vancomycin. The evolution was favourable in 90% of patients, but eight patients (10%) died This study highlights a high frequency of CDI in patients treated for tuberculosis. Due to insufficient data, no epidemiological consideration could be made. Further studies are needed to assess the relationship among tuberculosis, tuberculosis treatment and CDI.

Prevalence and Genotypes of Nosocomial Clostridium difficile Infections in the Eastern Province of the Kingdom of Saudi Arabia: A Multi-Centre Prospective Study

Prevalence and Genotypes of Nosocomial Clostridium difficile Infections in the Eastern Province of the Kingdom of Saudi Arabia: A Multi-Centre Prospective Study

Can the use of probiotics reduce the incidence of nosocomial Clostridium difficile infection in 60 years or older patients?

Background:Antibiotic-associated diarrhea (AAD) is a common side effect of antibiotic use. The pathogenesis of AAD may be mediated by disruption of the host’s normal flora resulting in overgrowth of pathogens. One of these pathogens is Clostridium difficile. Probiotics may help reestablish the disrupted intestinal flora and help clear the pathogen and its toxins from the host. Although numerous studies have been conducted, results are variable due to study design, type of probiotic, differing dose of probiotic, and duration of treatment. Our study aims to assess the efficacy and safety of the probiotics Lactobacillus GG and Saccharomyces boulardii for the prevention of C. difficile associated diarrhea.Methods:Study data were collected from two community hospitals in Kansas City over a period of 5 months. All patients in the study were initiated on antibiotics and were then given probiotics. This study was controlled and not blinded.Results:In data from two community hospitals, 816 patients who were being treated with antibiotics prior to the investigation served as a control; 14 (1.72%) had C. difficile Infections. During the study using probiotic administration, 803 patients also being treated with antibiotics prior to the investigation were followed and in this population; five patients (0.62%) contracted a C. difficile infection.

Effect of an antimicrobial stewardship programme on antimicrobial utilisation and costs in patients with leukaemia: a retrospective controlled study

ObjectivesTo examine the effectiveness of an antimicrobial stewardship programme on utilization and cost of antimicrobials in leukaemia patients in Canada. MethodsWe conducted a multisite retrospective observational time series study from 2005 to 2013. We implemented academic detailing as the intervention of an antimicrobial stewardship programme in leukaemia units at a hospital, piloted February–July 2010, then fully implemented December 2010–March 2013, with no intervention in August–November 2010. Internal control was the same hospital's allogeneic haematopoietic stem-cell transplantation unit. External control was the combined leukaemia–haematopoietic stem-cell transplantation unit at another hospital. Primary outcome was antimicrobial utilization (antibiotics and antifungals) in defined daily dose per 100 patient-days (PD). Secondary outcomes were antimicrobial cost (Canadian dollars per PD); cost and utilization by drug class; length of stay; 30-day inpatient mortality; and nosocomial Clostridium difficile infection. We used autoregressive integrated moving average models to evaluate the impact of the intervention on outcomes. ResultsThe intervention group included 1006 patients before implementation and 335 during full implementation. Correspondingly, internal control had 723 and 264 patients, external control 1395 and 864 patients. Antimicrobial utilization decreased significantly in the intervention group (p <0.01, 278 vs. 247 defined daily dose per 100 PD), increased in external control (p = 0.02, 237.4 vs. 268.9 defined daily dose per 100 PD) and remained stable in internal control (p = 0.66). Antimicrobial cost decreased in the intervention group (p = 0.03; $154.59 per PD vs. $128.93 per PD), increased in external control (p = 0.01; $109.4 per PD vs. $135.97 per PD) but was stable in internal control (p = 0.27). Mortality, length of stay and nosocomial C. difficile rate in intervention group remained stable. ConclusionsThe antimicrobial stewardship programme reduced antimicrobial use in leukaemia patients without affecting inpatient mortality and length of stay.

Hypervirulent Clostridium difficile Strains Are Rarely Associated With Nosocomial CDI in Adults in Lebanon: Results From a Prospective Study on the Incidence, Risk Factors for Relapse, and Outcome of Nosocomial CDI

Hypervirulent Clostridium difficile Strains Are Rarely Associated With Nosocomial CDI in Adults in Lebanon: Results From a Prospective Study on the Incidence, Risk Factors for Relapse, and Outcome of Nosocomial CDI

Analysis of toxin and multilocus sequence typing of Clostridium difficile strains isolated from China-Japan Friendship Hospital

Objective To analyze the characteristics of toxin, the PCR-ribotyping(RT) and the multilocus sequence typing(MLST) of Clostridium difficile strains isolated from China-Japan Friendship Hospital in order to provide a basis for monitoring the outbreak of nosocomial Clostridium difficile infection. Methods A total of 321 samples were collected from the patients with suspected Clostridium difficile infection(CDI) in China-Japan Friendship Hospital(CJFH) during 2012 to 2013. All Clostridium difficile strains were isolated and identified by the standard phenotypic culture method. Cytotoxicity test was performed to detect toxin B. Toxin genes (tcdA and tcdB) and binary toxin genes (cdtA and cdtB) harbored by those strains were analyzed. RT and MLST were used for homologous analysis. Clinical data of the patients were collected to analyze the isolation rate of Clostridium difficile in different populations. Results Forty-eight strains of Clostridium difficile were isolated from 46 patients with diarrhea and three of them were isolated from the same patient. The incidence of CDI among all patients, outpatients and inpatients were 14.3%(46/321), 12.8%(5/39) and 14.5%(41/282), respectively. Toxin B was detected in all of the strains as indicated by the cytotoxicity test. Strains of sequence type 1(ST1) showed the strongest cytotoxicity of all the isolated Clostridium difficile strains. Ten out of the 48 strains (20.8%) were tcdA(-)/tcdB(+ ) strains, which belonged to either ST37 or ST81. The results of RT and MLST were consistent in assigning the strains into nine types, in which the predominant type was ST1/RT027 accounting for 27.1% (13/48). All of the ST1/RT027 strains presented a toxin gene profile of tcdA(+ )/tcdB(+ ) and cdtA(+ )/cdtB(+ ). Most of the ST1/RT027 strains were isolated from the Traditional Chinese Medicine Department of Respiratory, where smallnosocomial outbreaks of ST1/RT027 strain infection might happen. Conclusion CDI diagnosed in CJFH mainly belongs to nosocomial infection. Most of the isolated strains harbor tcdA(+ )/tcdB(+ ) genes. Surveillance for the outbreaks of CDI caused by ST1/RT027 strains over producing toxins A and B should be strengthened in hospitals. Key words: Clostridium difficile; Standard phenotypic culture method; Cytotoxicity test; Ribotyping; Multilocus sequence typing