Clostridium difficile-associated disease acquired in the neurocritical care unit. Neurocrit Care. 2010;13:87-92. [PMID: 20443154 DOI: 10.1007/s12028-010-9374-x]

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Clostridioides difficile infection in neurosurgical patients in a national centre over 10 years: less common but associated with longer hospital stays

BACKGROUND

Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated (HA) diarrhoea, contributing to patient morbidity and prolonged length-of-stay (LOS). We retrospectively assessed CDI over a decade in a national neurosurgical centre, with a multi-disciplinary approach to CDI surveillance and antimicrobial stewardship, by comparing CDI patients with other patient groups.

METHODS

Data on CDI in neurosurgical inpatients between January 2012 and December 2021 were collated. Disease-specific variables were compared to other inpatients with CDI. Rates per 10,000 bed days used were calculated. Patient-specific differences were compared with neurosurgical patients without CDI. CDI rates by patient group were explored using odds ratio (OR) and χ2 analyses. Negative binomial regression was used to investigate CDI rates over time.

RESULTS

Of 50 neurosurgical patients with CDI, all were HA; the average age was 53 years (standard deviation (SD) 16.3 years), 49 were first-episode CDI, and three had severe CDI. The majority (76.7%) had received recent antimicrobials. Compared with non-neurosurgical CDI patients, neurosurgical CDI rates differed significantly (1.9 versus 3.6 per 10,000 bed days used, p < 0.05), neurosurgical patients were younger (p ≤ 0.01), C. difficile testing was more likely to be requested by neurosurgeons (OR 2.4; p ≤ 0.01), and the proportion of severe CDI was higher (6% versus 2%, OR 3.0, p = 0.07, confidence interval (CI) 0.54 to 11.3). Within the neurosurgical cohort, CDI patients had an average LOS four times that of other patients (CI 15.2 to 35.1; p < 0.01) and were older (53.5 versus 47.8 years, CI 0.1 to 11 years; p < 0.05). Only one CDI outbreak was linked to neurosurgical patients.

CONCLUSION

CDI in neurosurgery patients differed from the wider hospital, with greater awareness of CDI testing. Longer LOS impacted bed utilisation with limited capacity. Robust surveillance supports proactive antimicrobial stewardship programmes in this vulnerable population.

Retrospective Study of the Epidemiology of Clostridioides difficile Infection in the Neurosurgery Department of a Tertiary Hospital in China

Background

Although the epidemiology of Clostridioides difficile is important, few studies examining transmission of C. difficile have been reported, especially in wards with low detection rates, such as neurosurgery departments.

Purpose

This retrospective study investigated the epidemiology of C. difficile infection in a neurosurgery department over a 24-month period, particularly examining the transmission of C. difficile using whole-genome sequencing (WGS).

Methods

Clostridioides difficile strains were isolated and identified from fecal samples of neurosurgical patients. Toxigenic strains were typed using multilocus sequence typing, PCR ribotyping and using capillary gel electrophoresis. WGS was used to characterize C. difficile ST-37/RT017 isolates, and comparative genomic analyses were performed to compare genomic differences between all ST-37 strains from other wards. The susceptibility to 8 antimicrobial agents was examined using the E-test.

Results

Comparative genomic analyses revealed that isolates obtained from neurosurgical patients clustered into two lineages. Only strains s11052403 and s10090304, respectively, isolated from a patient on the 8th floor of the neurosurgery ward and a patient on the 9th floor, were highly similar, exhibiting differences of only two single-nucleotide polymorphisms. All C. difficile ST-37/RT017 strains isolated from neurosurgical patients were resistant to multiple classes of antibiotics.

Conclusion

There is an urgent need to raise awareness of C. difficile infection, and epidemiologic surveillance is required to detect clustering and transmission of C. difficile cases in China. Strict disinfection of the environment is essential to reduce transmission of C. difficile and achieve effective infection control in the hospital setting.

Clostridium difficile Infection Does Not Impact Outcomes in Stroke Patients

BACKGROUND

Data are limited for Clostridium difficile infection (CDI) in stroke patients. This study investigates incidence, patient characteristics, clinical features, and outcomes of CDI following stroke, including ischemic stroke (IS), intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (SAH).

METHODS

The hospital database was queried for all patients with IS, ICH, or SAH from 2010 through 2014. Patients who underwent testing for C. difficile testing (CDT) through polymerase chain reaction were assessed. Demographics, risk factors, clinical features, and outcomes were recorded. Fever was defined as temperature >101°F.

RESULTS

CDT was obtained in 555/4004 patients and was positive in 99, for CDI incidence of 2.5% [SAH 6.5% (26/402) vs. 2.9% in ICH (21/730) and 1.8% in IS (52/2872)]. There were no differences in demographics, severity [ICH score, National Institutes for Health Stroke Scale (NIHSS), Hunt Hess (HH), Glasgow coma scale (GCS)], mechanical ventilation, neurosurgical procedures, stress ulcer prophlyaxis or antibiotic use. Steroid use (P=0.0273) and male sex (P=0.0112) were associated with a positive CDT. On the day of diagnosis, 61% of CDT-positive patients had white blood cell <12, and 71% were afebrile. Length of stay, discharge disposition, mortality, and 3-month and 12-month modified Rankin, were not impacted by CDT results. Two patients with CDI required bowel resection.

CONCLUSION

CDI incidence following stroke was low and most common with SAH. Male sex and steroid use were associated with a positive result. Leukocytosis and fever occurred in under half of infected patients. Outcome measures were not impacted by CDI.

Clostridium difficile Infections in Medical Intensive Care Units of a Medical Center in Southern Taiwan: Variable Seasonality and Disease Severity

Critical patients are susceptible to Clostridium difficile infections (CDIs), which cause significant morbidity and mortality in the hospital. In Taiwan, the epidemiology of CDI in intensive care units (ICUs) is not well understood. This study was aimed to describe the incidence and the characteristics of CDI in the ICUs of a medical center in southern Taiwan. Adult patients with diarrhea but without colostomy/colectomy or laxative use were enrolled. Stool samples were collected with or without 5 ml alcohol and were plated on cycloserine-cefoxitin-fructose agar. C. difficile identification was confirmed by polymerase chain reaction. There were 1,551 patients admitted to ICUs, 1,488 screened, and 145 with diarrhea. A total of 75 patients were excluded due either to laxative use, a lack of stool samples, or refusal. Overall, 70 patients were included, and 14 (20%) were diagnosed with CDI, with an incidence of 8.8 cases per 10,000 patient-days. The incidence of CDI was found to be highest in March 2013 and lowest in the last quarter of 2013. The cases were categorized as the following: 5 severe, complicated, 5 severe, and 4 mild or moderate diseases. Among the 14 cases of CDI, the median patient age was 74 (range: 47-94) years, and the median time from admission to diarrhea onset was 16.5 (4-53) days. Eight cases received antimicrobial treatment (primarily metronidazole), and the time to diarrheal resolution was 11.5 days. Though 6 cases were left untreated, no patients died of CDI. The in-hospital mortality of CDI cases was 50%, similar to that of patients without CDI (46.4%; P = 1.0). We concluded that the overall incidence of CDI in our medical ICUs was low and there were variable seasonal incidences and disease severities of CDI.

Predictors of Clostridium difficile infection severity in patients hospitalised in medical intensive care

AIM: To describe and analyse factors associated with Clostridium difficile infection (CDI) severity in hospitalised medical intensive care unit patients.

METHODS: We performed a retrospective cohort study of 40 patients with CDI in a medical intensive care unit (MICU) at a French university hospital. We include patients hospitalised between January 1, 2007 and December 31, 2011. Data on demographics characteristics, past medical history, CDI description was collected. Exposure to risk factors associated with CDI within 8 wk before CDI was recorded, including previous hospitalisation, nursing home residency, antibiotics, antisecretory drugs, and surgical procedures.

RESULTS: All included cases had their first episode of CDI. The mean incidence rate was 12.94 cases/1000 admitted patients, and 14.93, 8.52, 13.24, 19.70, and 8.31 respectively per 1000 admitted patients annually from 2007 to 2011. Median age was 62.9 [interquartile range (IQR) 55.4-72.40] years, and 13 (32.5%) were women. Median length of MICU stay was 14.0 d (IQR 5.0-22.8). In addition to diarrhoea, the clinical symptoms of CDI were fever (> 38 °C) in 23 patients, abdominal pain in 15 patients, and ileus in 1 patient. The duration of diarrhoea was 13.0 (8.0-19.5) d. In addition to diarrhoea, the clinical symptoms of CDI were fever (> 38 °C) in 23 patients, abdominal pain in 15 patients, and ileus in 1 patient. Prior to CDI, 38 patients (95.0%) were exposed to antibiotics, and 12 (30%) received at least 4 antibiotics. Fluoroquinolones, 3^rd generation cephalosporins, coamoxiclav and tazocillin were prescribed most frequently (65%, 55%, 40% and 37.5%, respectively). The majority of cases were hospital-acquired (n = 36, 90%), with 5 cases (13.9%) being MICU-acquired. Fifteen patients had severe CDI. The crude mortality rate within 30 d after diagnosis was 40% (n = 16), with 9 deaths (9 over 16; 56.3%) related to CDI. Of our 40 patients, 15 (37.5%) had severe CDI. Multivariate logistic regression showed that male gender [odds ratio (OR): 8.45; 95%CI: 1.06-67.16, P = 0.044], rising serum C-reactive protein levels (OR = 1.11; 95%CI: 1.02-1.21, P = 0.021), and previous exposure to fluoroquinolones (OR = 9.29; 95%CI: 1.16-74.284, P = 0.036) were independently associated with severe CDI.

CONCLUSION: We report predictors of severe CDI not dependent on time of assessment. Such factors could help in the development of a quantitative score in ICU’s patients.

Increased hospital length of stay attributable to Clostridium difficile infection in patients with four co-morbidities: an analysis of hospital episode statistics in four European countries

Hospital-onset Clostridium difficile infection (CDI) places a significant burden on health care systems throughout Europe, estimated at around €3 billion per annum. This burden is shared between national payers and hospitals that support additional bed days for patients diagnosed with CDI while in hospital or patients re-admitted from a previous hospitalisation. This study was performed to quantify additional hospital stay attributable to CDI in four countries, England, Germany, Spain, and The Netherlands, by analysing nationwide hospital-episode data. We focused upon patients at increased risk of CDI: with chronic obstructive pulmonary disease, heart failure, diabetes, or chronic kidney disease, and aged 50 years or over. Multivariate regression and propensity score matching models were developed to investigate the impact of CDI on additional length of hospital stay, controlling for confounding factors such as underlying disease severity. Patients in England had the longest additional hospital stay attributable to CDI at 16.09 days, followed by Germany at 15.47 days, Spain at 13.56 days, and The Netherlands at 12.58 days, derived using regression analysis. Propensity score matching indicated a higher attributable length of stay of 32.42 days in England, 15.31 days in Spain, and 18.64 days in The Netherlands. Outputs from this study consistently demonstrate that in European countries, for patients whose hospitalisation is complicated by CDI, the infection causes a statistically significant increase in hospital length of stay. This has implications for optimising resource allocation and budget setting at both the national and hospital level to ensure that levels of CDI-complicated hospitalisations are minimised.

Clostridium difficile Associated Disease in a Neurointensive Care Unit

Background: Critically ill patients are at high risk for acquiring Clostridium difficile infection. The aim of this study was to investigate the prevalence, severity, and outcome of neurointensive care unit (NICU) acquired Clostridium difficile associated disease (CDAD).

Materials and Methods: Intensive care admission and hospital infection control databases from April 2008 to August 2010 were studied and the case notes reviewed retrospectively. Diarrhea was classified as mild, moderate, or severe based on the frequency and volume. Information on demographics, risk factors for CDAD, presentation, and course of the disease was gathered. Admission diagnosis, days of NICU stay, and incidence of complications were noted.

Results: In the time period studied, 9 out of 2212 patients (prevalence rate 0.4%) admitted to the intensive care unit (ICU) for a total of 10,825 bed days (incidence rate 8.3 per 10,000 bed days) acquired CDAD. Median age was 55 (IQR 20–72) years. The median NICU stay was 26 (IQR 11–103) days. The median duration between ICU admission and development of CDAD was 11 (IQR 3–93) days. Four patients (44%) had moderate CDAD. Concurrent infections occurred in seven (77%) patients. The most frequently prescribed antimicrobials prior to CDAD were cephalosporins (71%). The apparent risk factors in this group included age>65 year (22%) and antibiotics (67%) among others. One patient developed CDAD colitis. Three patients had a perceived delay in discharge from the ICU (1–8 days) due to their infective status. No mortality was ascribed to CDAD.

Conclusion: The prevalence rate (0.4%) and morbidity of CDAD in the unit are low. A larger database is needed to better analyze the associated risk factors in this subgroup of patients. A possible increase in disease burden due to a delay in discharge from the ICU merits further evaluation.

A genomic analysis of Clostridium difficile infections in blunt trauma patients

BACKGROUND

Evidence demonstrates that susceptibility to Clostridium difficile infection is related to host risk factors as much as bacterial potency. Using blood leukocyte genome-wide expression patterns of severe blunt trauma patients obtained by the National Institute of General Medical Sciences-sponsored Glue Grant Inflammation and the Host Response to Injury, we examined leukocyte genomic profiles of patients with C. difficile infection to determine preinfection and postinfection gene expression changes.

METHODS

The genomic responses of 21 severe trauma patients were analyzed (5 C. difficile, 16 controls matched for age and severity of injury). After elimination of probe sets whose expression was below baseline or were unchanged, remaining probe sets underwent hierarchical clustering and principal component analysis. Molecular pathways were generated through Ingenuity Pathways Analysis.

RESULTS

Supervised analysis demonstrated 118 genes whose expression in patients with C. difficile infection varied before and after their infection. Supervised analysis comparing patients with C. difficile infection with matched non-C. difficile patients before infection suggested that the expression of 501 genes were different in the two groups with up to 87% class prediction (p < 0.05). Many of these genes are related to cell-mediated immune responses, signaling, and interaction.

CONCLUSION

Genomic analysis of severe blunt trauma patients reveals a distinct leukocyte expression profile of C. difficile both before and after infection. We conclude that an association may exist between a severe trauma patient's leukocyte genomic expression profile and subsequent susceptibility to C. difficile infection. Further prospective expression analysis of this C. difficile population may reveal potential therapeutic interventions and allow early identification of C. difficile-susceptible patients.

LEVEL OF EVIDENCE

Prognostic/diagnostic study, level III.

Length of stay and mortality due to Clostridium difficile infection acquired in the intensive care unit

PURPOSE

The purpose of this study was to determine the attributable intensive care unit (ICU) and hospital length of stay and mortality of ICU-acquired Clostridium difficile infection (CDI).

MATERIALS AND METHODS

In this retrospective cohort study of 3 tertiary and 3 community ICUs, we screened all patients admitted between April 2006 and December 2011 for ICU-acquired CDI. Using both complete and matched cohort designs and Cox proportional hazards analysis, we determined the association between CDI and ICU and hospital length of stay and mortality. Adjustment or matching variables were site, age, sex, severity of illness, and year of admission; any infection as an ICU admitting or acquired diagnosis before the diagnosis of CDI and diagnosis of CDI were time-dependent exposures.

RESULTS

Of 15314 patients admitted to the ICUs during the study period, 236 developed CDI in the ICU. In the complete cohort analysis, the hazard ratios (95% confidence interval) for CDI related to ICU and hospital discharge were 0.82 (0.72, 0.94) and 0.83 (0.73, 0.95), respectively (0.5 additional ICU days and 3.4 hospital days), and related to death in ICU and hospital, they were 1.00 (0.73, 1.38) and 1.19 (0.93, 1.52), respectively. In the matched analysis, the hazard ratios for CDI related to ICU and hospital discharge were 0.91 (0.81, 1.03) and 0.98 (0.85, 1.13), respectively, and related to death in ICU and hospital, they were 1.18 (0.85, 1.63) and 1.08 (0.82, 1.43), respectively.

CONCLUSIONS

C difficile infection acquired in ICU is associated with an increase in length of ICU and hospital stay but not with any difference in ICU or hospital mortality.

Clinical and economic burden of Clostridium difficile infection in Europe: a systematic review of healthcare-facility-acquired infection

PubMed, EMBASE and conference abstracts were reviewed systematically to determine the clinical and economic burden associated with Clostridium difficile infection (CDI) acquired and treated in European healthcare facilities. Inclusion criteria were: published in the English language between 2000 and 2010, and study population of at least 20 patients with documented CDI acquired/treated in European healthcare facilities. Data collection was completed by three unblinded reviewers using the Cochrane Handbook and PRISMA statement. The primary outcomes were mortality, recurrence, length of hospital stay (LOS) and cost related to CDI. In total, 1138 primary articles and conference abstracts were identified, and this was narrowed to 39 and 30 studies, respectively. Data were available from 14 countries, with 47% of studies from UK institutions. CDI mortality at 30 days ranged from 2% (France) to 42% (UK). Mortality rates more than doubled from 1999 to 2004, and continued to rise until 2007 when reductions were noted in the UK. Recurrent CDI varied from 1% (France) to 36% (Ireland); however, recurrence definitions varied between studies. Median LOS ranged from eight days (Belgium) to 27 days (UK). The incremental cost of CDI was £4577 in Ireland and £8843 in Germany, after standardization to 2010 prices. Country-specific estimates, weighted by sample size, ranged from 2.8% to 29.8% for 30-day mortality and from 16 to 37 days for LOS. CDI burden in Europe was most commonly described using 30-day mortality, recurrence, LOS and cost data. The continued spread of CDI and resultant healthcare burden underscores the need for judicious use of antibiotics.

Investigation of pulmonary infection pathogens in neurological intensive care unit

Purpose:

The purpose of this study is to investigate the distribution and antimicrobial susceptibility of pathogenic bacteria in inpatients with pulmonary infection in the neurological intensive care unit (NICU).

Methods:

A total of 947 sputum specimens of 428 inpatients from May 2007 to May 2008 in the NICU were enrolled in the study, and bacterial identification and antibiotic susceptibility tests were analyzed using a VITEK 2 system.

Results:

A total of 400 positive bacterial strains were separated from 947 sputum specimens, with Gram-negative bacteria accounting for 69.0% of the total strains collected. The most common strain of Gram-negative bacteria was Klebsiella pneumoniae (20.5%). Gram-positive bacteria accounted for 10.0% of the total strains, with the most common strain being Staphylococcus aureus (2.5%). Fungal species accounted for 21.0% of the total strains, and the most common strain collected was Candida albicans (12.25%). Imipenem was the most effective antibiotic against Gram-positive and Gram-negative bacteria. The drug resistance rate of Gram-positive bacteria to penicillin G was 100%, and the Gram-positive bacteria were 100% sensitive to teicoplanin, vancomycin, and linezolid.

Conclusions:

Gram-negative bacterial infections account for the majority of pulmonary infections in the NICU, with fungal infections being the second most common infection type observed. In addition, fungal infections seem to be related to mortality in the NICU.