Risk Of Clostridium Difficile-associated Diarrhea Research Articles

Proton-pump inhibitors and the risk of Clostridium difficile-associated diarrhea in high-risk antibiotics users: A population-based case-crossover study.

Given the severity and high-costs demand of Clostridium difficile-associated diarrhea (CDAD), management of risk factors is very important. Although the association between proton-pump inhibitors (PPIs) and CDAD has been established, little is known among high-risk antibiotics users. This study aimed to identify the association between PPIs and CDAD in high-risk antibiotics users by using a case-crossover design. We conducted a case-crossover study using a nationwide population-based cohort in South Korea. Participants who developed CDAD from 1 January 2003 to 31 December 2013 and had prior prescription records of both PPIs and high-risk antibiotics were included. The hazard period was 49days, and the three prior control periods had the same duration as the hazard period. The status of exposure to PPIs was assessed during the hazard and control periods in each patient and discordant pairs of exposure were used to estimate the matched odds ratio (OR). In total, 200 participants with CDAD who had histories of both PPIs and high-risk antibiotics use were included. A twofold increased risk for CDAD due to PPI use was observed (OR=2.0; 95% confidence interval, 1.2-3.2). The time-invariant variables including age group, sex, and comorbidities were proven not to modify the association between PPIs and CDAD. Our study suggested that PPIs increase the risk of developing CDAD in high-risk antibiotics users. Thus, PPIs should be used cautiously in patients requiring high-risk antibiotics in the situation of medical treatment to prevent further incidence of CDAD.

Cost-effectiveness analysis of oral probiotics for the prevention of Clostridium difficile-associated diarrhoea in children and adolescents

The incidence of Clostridium difficile-associated diarrhoea (CDAD) in hospitalized children and adolescents has been increasing year-on-year. Paediatric CDAD places a significant economic burden on healthcare systems. Probiotics are live organisms thought to improve the microbial balance of the host, counteract disturbances in intestinal flora, and reduce the risk of colonization by pathogenic bacteria. A cost-effectiveness analysis was conducted to assess the economy of probiotics for the prevention of CDAD in children and adolescents receiving antibiotics. A decision tree model combining clinical effectiveness, utility and cost data was used. Sensitivity analyses were conducted to determine the robustness of the model outcomes. The 'oral probiotics' strategy and 'no probiotics' strategy offered patients 0.05876 and 0.056 quality-adjusted life years (QALYs) at a cost of $16,668.70 and $20,355.28, respectively. The oral probiotics strategy exhibited higher QALY and lower cost, and represents the cost-saving strategy. The results were robust for sensitivity analyses. From the perspective of the medical system, oral probiotics as a preventive strategy for CDAD in hospitalized children and adolescents receiving a therapeutic course of antibiotics reduced the risk of CDAD and represents a cost-saving strategy.

Levofloxacin for febrile neutropenia prophylaxis in acute myeloid leukemia patients associated with reduction in hospital admissions.

The purpose of this study is to evaluate the efficacy and safety of prophylactic oral levofloxacin in acute myeloid leukemia (AML) patients after receiving consolidation chemotherapy to prevent febrile neutropenia. We conducted a retrospective chart review of 50 AML patients who were prescribed levofloxacin and 50 AML patients who were not prescribed levofloxacin post-consolidation chemotherapy between June 2006 and August 2013 at a tertiary academic medical center. The primary outcome of this study was to evaluate the effectiveness of levofloxacin in preventing hospital readmission due to febrile neutropenia. Secondary outcomes evaluated the safety of this therapy, including the rate of Clostridium difficile-associated diarrhea (CDAD) within 30days from discharge of receiving consolidation chemotherapy and rate of fluoroquinolone resistance in positive bacterial cultures. Hospital readmission due to febrile neutropenia after the first consolidation cycle occurred in 42% of patients prescribed levofloxacin, as compared to 72% that were not prescribed levofloxacin (p = 0.002). This was also significantly reduced when levofloxacin was prescribed after all consolidation cycles (51.4 vs. 67%, p = 0.023). CDAD did not occur in any patient prescribed levofloxacin after the first cycle, compared to one case in those not prescribed levofloxacin. Evaluation of the impact on fluoroquinolone resistance was limited due to a paucity of fluoroquinolone susceptibilities reported. Prescribing oral levofloxacin post-consolidation chemotherapy in AML patients is associated with a reduction in febrile neutropenia. Further research is required to identify the impact on fluoroquinolone resistance and risk of CDAD.

Rifaximin treatment is associated with reduced risk of cirrhotic complications and prolonged overall survival in patients experiencing hepatic encephalopathy.

Rifaximin might decrease the risk of portal hypertension-related complications by controlling small intestinal bacterial overgrowth. To evaluate whether rifaximin was associated with the risk of death and cirrhotic complications. We conducted a retrospective study that included 1042 patients experiencing hepatic encephalopathy (HE): 421 patients without hepatocellular carcinoma (HCC; the non-HCC cohort) and 621 patients with HCC (the HCC cohort). The primary endpoint was overall survival and secondary endpoints were recurrence of HE and the development of spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS) and variceal bleeding. In the non-HCC cohort, 145 patients received rifaximin plus lactulose (the rifaximin group) and 276 patients received lactulose alone (the control group). The multivariate analysis revealed that rifaximin was significantly associated with lower risk of death (adjusted hazard ratio [aHR], 0.697; P = .024) and reduced the risk of recurrent HE (aHR, 0.452; P < .001), SBP (aHR, 0.210; P < .001) and variceal bleeding (aHR, 0.425; P = .011) but not HRS (aHR, 0.598; P = .08). In the HCC cohort, 173 patients received rifaximin plus lactulose and 448 patients received lactulose. Rifaximin was not associated with the risk of death (aHR, 1.177; P = .121). Rifaximin was associated with lower risk of SBP (aHR, 0.323; P < .001) but not with variceal bleeding (aHR, 0.660; P = .104) or recurrent HE (aHR, 0.689; P = .057). The risk of Clostridium difficile-associated diarrhoea was not different between the groups (aHR, 0.028; P = .338). In patients without HCC, rifaximin treatment was significantly associated with prolonged overall survival and reduced risks of spontaneous bacterial peritonitis, variceal bleeding and recurrent hepatic encephalopathy.

Cost-Effectiveness Analysis of the Use of Probiotics for the Prevention of Clostridium difficile-Associated Diarrhea in a Provincial Healthcare System.

OBJECTIVE To conduct a full economic evaluation assessing the costs and consequences related to probiotic use for the primary prevention of Clostridium difficile-associated diarrhea (CDAD). DESIGN Cost-effectiveness analysis using decision analytic modeling. METHODS A cost-effectiveness analysis was used to evaluate the risk of CDAD and the costs of receiving oral probiotics versus not over a time horizon of 30 days. The target population modeled was all adult inpatients receiving any therapeutic course of antibiotics from a publicly funded healthcare system perspective. Effectiveness estimates were based on a recent systematic review of probiotics for the primary prevention of CDAD. Additional estimates came from local data and the literature. Sensitivity analyses were conducted to assess how plausible changes in variables impacted the results. RESULTS Treatment with oral probiotics led to direct costs of CDN $24 per course of treatment per patient. On average, patients treated with oral probiotics had a lower overall cost compared with usual care (CDN $327 vs $845). The risk of CDAD was reduced from 5.5% in those not receiving oral probiotics to 2% in those receiving oral probiotics. These results were robust to plausible variation in all estimates. CONCLUSIONS Oral probiotics as a preventive strategy for CDAD resulted in a lower risk of CDAD as well as cost-savings. The cost-savings may be greater in other healthcare systems that experience a higher incidence and cost associated with CDAD. Infect Control Hosp Epidemiol 2016;37:1079-1086.

Effect of Nutritional Status on Length of Hospital Stay in Patients With Clostridium difficile-Associated Diarrhea

Introduction:Clostridium difficile associated diarrhea (CDAD) is one of the most common nosocomial infections in hospitals and long term care facilities. Low serum albumin and serum protein, which are surrogates of nutritional status, are associated with increased incidence of CDAD and worse outcomes in patients with CDAD. However, these measures are crude and non-specific and there are no studies to date which demonstrate a direct association between the nutritional status - as assessed by standardized, replicable criteria - with outcomes of patients with CDAD. We aim to show that an Aspen Nutritional Index (ASI) is a more valid and accurate instrument to measure underlying malnutrition in patients with CDAD. Methods: We performed a retrospective cross-sectional study from April 2013 to June 2014. Hospitalized patients ≥ 18 years of age were included and divided into two groups: study group (diarrhea with a positive assay for antigen and toxins for c. difficile) and a control group (patients with negative assay for antigen and toxin for c. difficile). Each group was then subdivided into a non-malnourished group and a malnourished group according to the ASI (based on the 2012 ASPEN guidelines). Demographic data, Charlson comorbidity index (CMI), nutritional assessment, and, length of stay (LOS) were studied for each patient. All-cause mortality was also recorded for secondary outcomes. The inclusion criteria, exclusion criteria and all definitions were defined prior to the study. Results: A total of 314 patients were included: 148 patients in the study group (89 malnourished and 59 non-malnourished) and 166 in the control group (132 malnourished and 34 non-malnourished). Malnourished patients with CDAD had the longest LOS compared to other groups (Table 1). Malnourished patients with CDAD compared to non-malnourished control patients had a significantly increased LOS, mean±S.E. LOS (16.73±1.69 versus 11.35±1.33 days) (p=0.014). In addition, malnourished patients with CDAD had the highest all-cause mortality compared to the other groups (Table 2). All-cause mortality rate of malnourished patients with CDAD compared to non-malnourished control patients was 24.7% versus 5.9% (p=0.021). Mean CMI was 7±1 for all groups.Table 1: Mean length of stay between groups(in days)Table 2: Percentage all-cause mortalityConclusion: Malnourishment leads to prolonged LOS and increases all-cause mortality in CDAD. The ASI is the most accurate measure of underlying nutritional status and should be calculated in all patients with, or at risk for CDAD.

Systematic review with meta-analysis: Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea.

Antibiotic-associated diarrhoea is a common complication of antibiotic use, but it can be prevented with administration of probiotics. To update our 2005 meta-analysis on the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhoea in children and adults. The Cochrane Library, MEDLINE, and EMBASE databases were searched up until May 2015, with no language restrictions, for randomised controlled trials; additional references were obtained from reviewed articles. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Twenty-one randomised controlled trials (4780 participants), among which 16 were new trials, met the inclusion criteria for this updated systematic review. Administration of S.boulardii compared with placebo or no treatment reduced the risk of antibiotic-associated diarrhoea (as defined by the study investigators) in patients treated with antibiotics from 18.7% to 8.5% (risk ratio, RR: 0.47; 95% CI: 0.38-0.57, number needed to treat, NNT: 10; 95% CI: 9-13). In children, S. boulardii reduced the risk from 20.9% to 8.8% (6 randomised controlled trials, n=1653, RR: 0.43, 95% CI: 0.3-0.6); in adults, from 17.4% to 8.2% (15 randomised controlled trials, n=3114, RR: 0.49, 95% CI: 0.38-0.63). Moreover, S.boulardii reduced the risk of Clostridium difficile-associated diarrhoea; however, this reduction was significant only in children (2 randomised controlled trials, n=579, RR: 0.25; 95% CI: 0.08-0.73) and not in adults (9 randomised controlled trials, n=1441, RR: 0.8, 95% CI: 0.47-1.34). This meta-analysis confirms that S.boulardii is effective in reducing the risk of antibiotic-associated diarrhoea in children and adults.

Is co-prescribing a multi-strain probiotic the solution for treating and preventing proton pump inhibitor (PPIs) induced Clostridium difficile associated diarrhoea (CDAD) while maintaining evidence based pharmacotherapy?

A recent study investigating faecal transplants to eliminate Clostridium difficile infections has elicited further interest regarding the pharmacobiotic potential of the human gastrointestinal microbiome. Probiotic preparations may exhibit significant potential for the treatment of CDAD. Probiotics are defined as living organisms in food and dietary supplements that, upon ingestion, can improve the health of the host beyond their inherent basic nutritional content. The human–microbial gastrointestinal tract (GIT) interface is an ecosystem that participates in a variety of important roles in human health and disease. Maintaining this ecosystem in a balanced state is a critical requisite for the control of pathogenic bacteria and the associated toxin load produced in the small and large bowel. Pharmacotherapy induced adverse metabolic conditions that ensue can disrupt the GIT homeostasis and contribute toward a dysbiotic burden that increases the risk of CDAD.

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.

Ceftaroline Fosamil: A Review of its Use in the Treatment of Complicated Skin and Soft Tissue Infections and Community-Acquired Pneumonia

Ceftaroline, the active metabolite of the prodrug ceftaroline fosamil (Zinforo, Teflaro), is an advanced-generation, parenteral cephalosporin with broad-spectrum antibacterial activity in vitro against Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and multidrug resistant Streptococcus pneumoniae and Gram-negative bacteria, including Haemophilus influenzae and Moraxella catarrhalis, but not Pseudomonas aeruginosa. Ceftaroline has demonstrated a low potential for the selection of resistance in vitro for drug-resistant Gram-positive organisms, including MRSA, as well as for Gram-negative respiratory pathogens. In pivotal phase III studies, intravenous ceftaroline fosamil demonstrated noninferiority to intravenous vancomycin plus aztreonam in patients hospitalized with complicated skin and soft tissue infections (cSSTIs) and intravenous ceftriaxone in patients hospitalized with community-acquired pneumonia (CAP) [Pneumonia Outcomes Research Team (PORT) risk class III or IV]; however, patients with CAP admitted to the intensive care unit were not evaluated. Ceftaroline fosamil was generally well tolerated in these trials, with an adverse event profile similar to that of other cephalosporins. Diarrhoea was the most commonly reported adverse event; however, the risk of Clostridium difficile-associated diarrhoea with ceftaroline fosamil appeared to be low. Potential limitations of the drug include the lack of an oral formulation and the requirement for twice-daily administration. Nonetheless, ceftaroline fosamil represents an attractive option (either alone or in combination with other agents) for the initial empirical treatment of patients hospitalized with cSSTIs (including those with suspected MRSA infection) or CAP (PORT risk class III or IV) who require intravenous antimicrobial therapy. As with all antibacterial agents, ceftaroline fosamil should be used in accordance with good antimicrobial stewardship.

Resolution ofClostridium difficile–Associated Diarrhea in Patients With Cancer Treated With Fidaxomicin or Vancomycin

Patients with cancer are at increased risk for Clostridium difficile-associated diarrhea (CDAD). Little is known about treatment response. Two double-blind trials randomly allocated 1,105 patients with CDAD to fidaxomicin or vancomycin treatment (modified intent-to-treat [mITT]), and 183 of these had cancer. Univariate and multivariate post hoc analyses compared effects of treatment and patient characteristics on cure, recurrence, and sustained response after 4 weeks. Time to resolution of diarrhea (TTROD) was also evaluated. Patients with cancer had a lower cure rate and longer TTROD than patients without cancer. Recurrence rates were similar. Cure was more likely with fidaxomicin than vancomycin (odds ratio [OR] 2.0; P = .065), recurrence was less likely (OR = 0.37; P = .018), and sustained response more frequent (OR = 2.56; P = .003). Under vancomycin, median TTROD was longer in patients with cancer than in those without (123 v 58 hours; log-rank P < .001). With fidaxomicin, median TTROD was not significantly affected by presence of cancer (74 v 54 hours; log-rank P = .145). In the full mITT population, age, hypoalbuminemia, and cancer were inversely associated with clinical cure by multivariate analysis. Study treatment with vancomycin was a significant predictor of recurrence (P < .001). Within the cancer population, low albumin was negatively and fidaxomicin was positively associated with improved cure. For patients with cancer, fidaxomicin treatment was superior to vancomycin, resulting in higher cure and sustained response rates, shorter TTROD, and fewer recurrences.

Clostridium difficile-associated diarrhea in dialysis patients

BackgroundDialysis patients have impaired host defense mechanisms and frequently require antibiotics for various infective complications. In this study, we investigated whether dialysis patients have greater risk for Clostridium difficile-associated diarrhea (CDAD). MethodsDuring the 4-year study period (2004–2008), 85 patients with CDAD were identified based on a retrospective review of C difficile toxin assay or histology records. Nosocomial diarrheal patients without CDAD were considered as controls (n=403). We assessed the association between renal function and the prevalence and clinical outcomes of CDAD. ResultsThere was a significant difference in the prevalence rate of chronic kidney disease (CKD) between CDAD and non-CDAD patients (P<0.001). Sixteen patients (18.8%) of the CDAD group were treated with dialysis, whereas 21 patients (5.2%) of the non-CDAD group were treated with dialysis. There was a significant association between renal function and CDAD in patients on dialysis [odds ratio (OR)=4.44, 95% confidence interval (CI) 2.19–8.99, P<0.001], but not in patients with CKD stage 3–5 (OR=1.10, 95% CI 0.63–1.92, P=0.73). In multivariate analysis, CKD stage 5D was an independent risk factor for the development of CDAD (OR=13.36, 95% CI 2.94–60.67, P=0.001). ConclusionOur data indicate that dialysis patients might be at a greater risk of developing CDAD, which suggests that particular attention should be provided to CDAD when antibiotic treatment is administered to dialysis patients.

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.

Inappropriate Use of Gastric Acid Suppression Therapy in Hospitalized Patients with Clostridium difficile—Associated Diarrhea: A Ten-Year Retrospective Analysis

Purpose. The incidence of Clostridium difficile-associated diarrhea (CDAD) has steadily increased over the past decade. A multitude of factors for this rise in incidence of CDAD have been postulated, including the increased use of gastric acid suppression therapy (GAST). Despite the presence of practice guidelines for use of GAST, studies have demonstrated widespread inappropriate use of GAST in hospitalized patients. We performed a retrospective analysis of inpatients with CDAD, with special emphasis placed on determining the appropriateness of GAST. Methods. A retrospective analysis was conducted at a multidisciplinary teaching hospital on inpatients with CDAD over a 10-year period. We assessed the use of GAST in the cases of CDAD. Data collection focused on the appropriate administration of GAST as defined by standard practice guidelines. Results. An inappropriate indication for GAST was not apparent in a majority (69.4%) of patients with CDAD. The inappropriate use of GAST was more prevalent in medical (86.1%) than on surgical services (13.9%) (P < 0.001). There were more cases (67.6%) of inappropriate use of GAST in noncritical care than in critical care areas (37.4%) (P < 0.001). Conclusion. Our study found that an inappropriate use of inpatient GAST in patients with CDAD was nearly 70 percent. Reduction of inappropriate use of GAST may be an additional approach to reduce the risk of CDAD and significantly decrease patient morbidity and healthcare costs.

The incremental economic burden of clostridium-difficile associated diarrhea among hospitalized immunocompromised patients undergoing chemotherapy.

e16542 Background: Hospital-acquired Clostridium-difficile associated diarrhea (CDAD) results in an estimated $1.3 billion in excess costs in the US. Patients undergoing chemotherapy are at elevated risk of CDAD due to diminished immune response and increased exposure to health care facilities. This study describes the incremental economic burden of CDAD in hospitalized immunocompromised (IC) patients. Methods: IC cases (undergoing chemotherapy or other qualifying conditions) hospitalized with a diagnosis of CDAD having ≥12 months of prior health plan eligibility and age ≥18 years between 1/1/2005 and 10/31/2010 were identified from the HealthCore Integrated Research Database (HIRDSM). Cases were matched to hospitalized IC controls without CDAD diagnosis based on: age±10 years, gender, selected preceding/in-hospital comorbidities and use of antibiotics. Incremental hospital length of stay (LOS) and costs were calculated between matched cases and controls via multivariate methods using a Gamma distribution. Covariates were determined from post-match univariate analysis of baseline characteristics. Results: 3,586 cases were matched to 10,758 controls. Chemotherapy occurred among 91.3% of cases and controls. While age (65±15), gender (53% female), and selected comorbidities were balanced between cases and controls, post-match disparities persisted (p&lt;.001): geographic region (37% vs. 32% Midwest), type of health plan (24 vs. 18% HMO), overall comorbidity burden (6.0±3.6 vs. 6.5±3.7 Deyo-Charlson Comorbidity Index). Cases had a lower incidence of mortality during their index hospitalization (6.7% vs. 7.8%; p&lt;0.0001). Adjusted hospital LOS was significantly greater for cases vs. controls (22.1 days (20.61 to 23.69) vs. 13.67 days (12.74 to 14.67); p&lt;.0001). Incremental hospitalization costs indicated a significantly greater economic burden among cases vs.controls (Δ = $32K ($29K to $35K); p&lt;0.0001). Conclusions: This study indicates that the acquisition of CDAD among immunocompromised patients, of which chemotherapy recipients represented the majority, presents significant incremental economic burden within the hospital setting.

Underestimation of Clostridium difficile infection among clinicians: an international survey

The objective of this investigation was to document clinicians' awareness regarding the incidence and severity of Clostridium difficile-associated diarrhea (CDAD). An international electronic survey was conducted among corresponding authors of articles indexed by PubMed and published during the last 10years in 'Core Clinical Journals'. A total of 1,163 clinicians answered (response rate 59%); most of the responses were submitted from North America (54.6%), Europe (32.2%), and Asia/Pacific (11.6%). Only 2.2% of the participants answered correctly all four questions, while 14.1% answered all questions incorrectly. Regarding each question, 10.8% of the participants correctly estimated current CDAD treatment failure or recurrence rates to be around 40%, 33.4% correctly estimated the ratio of antibiotic-associated colitis attributed to C. difficile to be around 60%, 72.7% correctly responded that almost all antibiotics are associated with CDAD, and 41.7% correctly responded that any patient is at risk for CDAD. Almost half (44.4%) of the respondents considered CDAD to be underestimated. Participants from North America scored higher than those from Europe or Asia/Pacific (p < 0.001). Participants considering CDAD to be overestimated (3.4%) had the lowest mean score of correct answers. Among a clinically diverse international sample of physicians with academic expertise, there was an inadequate level of awareness of the magnitude and clinical importance of CDAD.

Proton pump inhibitor (PPI) use increases the risk of Clostridium difficile-associated diarrhoea (CDAD),

Proton pump inhibitor (PPI) use increases the risk of Clostridium difficile-associated diarrhoea (CDAD),

Sternal surgical site infection prevention – is there any room for improvement?

The objectives of this multicenter study are to evaluate current clinical practices in cardiac surgery concerning the prevention and management of sternal wound infections, to identify room for improvement, and to support implementation of systematic measures. As a part of a campaign for infection prevention in cardiac surgery in Germany, a multiple-choice questionnaire with two main sections was developed and submitted to all cardiac surgery units in Germany (79). The project was realized in cooperation with the German Society for Thoracic and Cardiovascular Surgery, the BQS Institute for Quality and Patient Safety, and the National Reference Center for Nosocomial Infection Surveillance. A representative number (54 of 79 or 68%) of German cardiac surgery centers participated in the survey, in which heterogeneous procedures and various standards for prevention were observed. Surveillance, standards, and advanced training regarding hygiene measures are present in almost all participating hospitals. Methicillin-resistant Streptococcus aureus (MRSA) screening is performed in 81.5% (44/54) of all participating departments. A little less than one-tenth (7.4%) perform decolonization measures on all patients, while 85.2% perform decolonization measures only on MRSA-positive patients. Application of perioperative antibiotic prophylaxis ranges from single-shot application to 3 days of treatment. Longer treatment is expensive and time-intensive, and also increases the risk of Clostridium difficile-associated diarrhea. Nearly three-quarters (70.4%) of all participating hospitals perform preoperative hair removal 1 day before surgery. Common techniques are clipping machines (53.7%), razors (40.7%), clipping machines and depilatory cream (1.9%), or depilatory cream only (1.9%). Remanent (37.0%) and non-remanent disinfectants (55.6%) are used for preoperative skin disinfection. The time of the first wound-dressing change varies from the day of surgery (1.9%) over the first (42.6%) or second (46.3%) day after surgery to up to 3 or more days after surgery (9.3%). The results of the evaluation show that basic measures for infection prevention in cardiac surgery in Germany are well implemented. Nevertheless, a relevant heterogeneity in the use of special measures was observed, although research-based guidelines for infection prevention in surgery do exist and many studies have demonstrated the usefulness and feasibility of these measures.

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.

Safety of the long-term use of proton pump inhibitors

The proton pump inhibitors (PPIs) as a class are remarkably safe and effective for persons with peptic ulcer disorders. Serious adverse events are extremely rare for PPIs, with case reports of interstitial nephritis with omeprazole, hepatitis with omeprazole and lansoprazole, and disputed visual disturbances with pantoprazole and omeprazole. PPI use is associated with the development of fundic gland polyps (FGP); stopping PPIs is associated with regression of FGP. In the absence of Helicobacter pylori infection, the long-term use of PPIs has not been convincingly proven to cause or be associated with the progression of pre-existing chronic gastritis or gastric atrophy or intestinal metaplasia. Mild/modest hypergastrinemia is a physiological response to the reduction in gastric acid secretion due to any cause. The long-term use of PPIs has not been convincingly proven to cause enterochromaffin-like cell hyperplasia or carcinoid tumors. PPIs increase the risk of community acquired pneumonia, but not of hospital acquired (nosocomial) pneumonia. There is no data to support particular care in prescribing PPI therapy due to concerns about risk of hip fracture with the long-term use of PPIs. Long-term use of PPIs does not lead to vitamin B12 deficiencies, except possibly in the elderly, or in persons with Zollinger-Ellison Syndrome who are on high doses of PPI for prolonged periods of time. There is no convincingly proven data that PPIs increase the risk of Clostridium difficile-associated diarrhea in persons in the community. The discontinuation of PPIs may result in rebound symptoms requiring further and even continuous PPI use for suppression of symptoms. As with all medications, the key is to use PPIs only when clearly indicated, and to reassess continued use so that long-term therapy is used judiciously. Thus, in summary, the PPIs are a safe class of medications to use long-term in persons in whom there is a clear need for the maintenance of extensive acid inhibition.