Clostridium difficile as a cause of acute diarrhea: a prospective study in a tertiary care center

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.

Surveillance and epidemiology of Clostridioides difficile infection using the national health surveillance network criteria: A 7-year study from Mumbai, India

INTRODUCTION

Clostridioides difficile (CD) is a significant cause of morbidity and mortality. While considerable data is available in the developed world regarding Clostridioides difficile infection (CDI), Indian data is sparse especially using the standardized surveillance systems.

AIM AND OBJECTIVES OF THE STUDY

To identify the incidence, risk factors, and mortality rate associated with CDI in a tertiary care hospital based on the Laboratory-Identified (LabID) event criteria of the Centers for Disease Control and Prevention (CDC) National Health Surveillance Network (NHSN).

MATERIALS AND METHODS

During a 7- year prospective observational study, CDI was diagnosed using CD polymerase chain reaction (PCR). CDI Laboratory-Identified (LabID) events were classified using the CDC NHSN surveillance definition, and CDI incidence was calculated per 10,000 Patient Days (PDs). Clinical details were collected as part of healthcare-associated infection (HCAI) surveillance. Healthcare Facility-Onset (HO) and Community-Onset Healthcare Facility-Associated (CO-HCFA) incident CDI events were analyzed further.

RESULTS

Among 898 tested stool samples, 77 CDI LabID events were observed, with 68 being Incident events. Of 68 events, 76.5% (52/68), 19.1% (13/68), and 4.4% (3/68) were HO, Community-Onset (CO), and CO-HCFA CDI events respectively. The overall incidence of CDI events was 1.66 per 10,000 PDs. Risk factors observed were antibiotics exposure (100%), comorbidities (87.3%), antacids exposure (87.3%), age over 60 years (80%), and hospitalization within the past 6 months (67.3%). The crude mortality rate was 25.5% (14/55).

CONCLUSION

These findings highlight the predominance of HO-CDI and the need for further investigation into CO-CDI in the Indian context to identify at-risk populations. Utilizing standardized surveillance methods such as NHSN definitions can facilitate accurate disease burden estimation, trend monitoring, and meaningful comparisons with global data.

Does this patient have Clostridioides difficile infection? A systematic review and meta-analysis

BACKGROUND

The clinical features and predictors of Clostridioides difficile infection overlap with many conditions.

OBJECTIVES

We performed a systematic review to evaluate the diagnostic utility of clinical features (clinical examination, risk factors, laboratory tests, and radiographic findings) associated with C. difficile.

METHODS

Systematic review and meta-analysis of diagnostic features for C. difficile.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched up to September 2021.

STUDY ELIGIBILITY CRITERIA

Studies that reported clinical features of C. difficile, a valid reference standard test for confirming diagnosis of C. difficile, and a comparison among patients with a positive and negative test result.

PARTICIPANTS

Adult and paediatric patients across diverse clinical settings.

OUTCOMES

Sensitivity, specificity, likelihood ratios.

REFERENCE STANDARD

Stool nucleic acid amplification tests, enzyme immunoassays, cell cytotoxicity assay, and stool toxigenic culture.

ASSESSMENT OF RISK OF BIAS

Rational Clinical Examination Series and Quality Assessment of Diagnostic Accuracy Studies-2.

METHODS OF DATA SYNTHESIS

Univariate and bivariate analyses.

RESULTS

We screened 11 231 articles of which 40 were included, enabling the evaluation of 66 features for their diagnostic utility for C. difficile (10 clinical examination findings, 4 laboratory tests, 10 radiographic findings, prior exposure to 13 antibiotic types, and 29 clinical risk factors). Of the ten features identified on clinical examination, none were significantly clinically associated with increased likelihood of C. difficile infection. Some features that increased likelihood of C. difficile infection were stool leukocytes (LR+ 5.31, 95% CI 3.29-8.56) and hospital admission in the prior 3 months (LR+ 2.14, 95% CI 1.48-3.11). Several radiographic findings also strongly increased the likelihood of C. difficile infection like ascites (LR+ 2.91, 95% CI 1.89-4.49).

DISCUSSION

There is limited utility of bedside clinical examination alone in detecting C. difficile infection. Accurate diagnosis of C. difficile infection requires thoughtful clinical assessment for interpretation of microbiologic testing in all suspected cases.

A worldwide systematic review and meta-analysis of bacteria related to antibiotic-associated diarrhea in hospitalized patients

INTRODUCTION

Antibiotic-associated diarrhea (AAD) is a major hospital problem and a common adverse effect of antibiotic treatment. The aim of this study was to investigate the prevalence of the most important bacteria that cause AAD in hospitalized patients.

MATERIALS AND METHODS

PubMed, Web of Science and Scopus databases were searched using multiple relevant keywords and screening carried out based on inclusion/exclusion criteria from March 2001 to October 2021. The random-effects model was used to conduct the meta-analysis.

RESULTS

Of the 7,377 identified articles, 56 met the inclusion criteria. Pooling all studies, the prevalence of Clostridioides (Clostridium) difficile, Clostridium perfringens, Klebsiella oxytoca, and Staphylococcus aureus as AAD-related bacteria among hospitalized patients were 19.6%, 14.9%, 27%, and 5.2%, respectively. The prevalence of all four bacteria was higher in Europe compared to other continents. The highest resistance of C. difficile was estimated to ciprofloxacin and the lowest resistances were reported to chloramphenicol, vancomycin, and metronidazole. There was no or little data on antibiotic resistance of other bacteria.

CONCLUSIONS

The results of this study emphasize the need for a surveillance program, as well as timely public and hospital health measures in order to control and treat AAD infections.

Clostridioides difficile Diarrhea: An Emerging Problem in a South Indian Tertiary Care Hospital

Context Clostridioides difficile infection (CDI) is one of the most common infectious causes of hospital-acquired diarrhea. The actual burden of the disease is underestimated in India due to inadequate diagnostic methods and limited studies conducted.

Aims The aim of this study was to determine the burden and risk factors of CDI among patients with hospital-acquired diarrhea.

Methods and Materials Stool specimen of patients (age > 1 year) with hospital-acquired diarrhea were screened for glutamate dehydrogenase antigen and toxin using an enzyme immunoassay. If both antigen and toxin were present, it was reported as positive for toxigenic CDI. Samples positive for antigen and negative for toxin were further tested with Cepheid GeneXpert assay for detecting the toxin producing gene.

Results Of 75 patients (mean age 36.07 ± 20.79, 64% males), 14 (18.67%) patients were positive for toxigenic Clostridioides difficile (C. difficile) and 3 (4%) patients were nontoxigenic C. difficile. Addition of GeneXpert to the testing algorithm increased the yield of toxin detection in 5/14 patients who were negative by toxin assay. On analysis of risk factors, prolonged hospital stay was found to have significant association (p-value = 0.022). Patients with factors like intensive care unit stay, presence of diabetes mellitus as a comorbidity, and exposure to antibiotics like carbapenems and glycopeptides have been found to have a higher prevalence of CDI.

Conclusions The prevalence of CDI in our population was 18.67% and the major risk factor associated was prolonged hospital stay. The addition of GeneXpert for the detection of toxin gene increased the yield from 12 to 18.68%.

The utility of multiplex polymerase chain reaction for diagnosis of infectious diarrhoea in a tropical country

PURPOSE

The etiology of infective diarrheaoften remains undiagnosed. We studied the role of multiplex polymerase chain reaction (PCR) for detection of etiological agents of diarrhoea.

METHODS

Fast track diagnostics (FTD)gastroenteritis panel for bacterial and viral pathogens was used to test stool samples from patients with diarrhoea.

RESULTS

Stool samples from 276 patients (138 immunocompetent and 138 immunocompromised) with diarrhoea and 138 healthy controls were tested. Bacterial culture was positive in 5 samples. Following agents were isolated: Shigella sonnei(2), Shigella dysentriae(1), SalmonellaParatyphi B(1) and Vibrio cholerae (1). Multiplex PCR panel did not include Vibrio cholerae in its panel. A total of 65 target pathogens were identified in 60/276 (21.7%) patients by multiplex PCR. 28/65(41.1%) and 37/65 (56.9%) were bacterial and viral agents respectively. Identified bacteria were Shigella(20), Salmonella(3), Campylobacter(4) and Clostridium difficile(1). Viral targets identified were Norovirus GII (28), Adenovirus(4), Astrovirus(3) and Sapovirus(2). All the controls were negative for enteropathogens by conventional methods and multiplex PCR.

CONCLUSIONS

Our detection rates increased from 1.8% (5/276)by conventional methods to 21.7% (60/276)by multiplex PCR, which included both bacterial as well as viral targets.

Systematic Literature Review on Burden of Clostridioides difficile Infection in India

BACKGROUND

Owing to limited diagnostic facilities and surveillance protocols, there is a paucity on the prevalence data of Clostridioides difficile infections (CDIs) in developing countries such as India.

OBJECTIVE

The aims of these studies are (1) to determine the prevalence of CDI in India, (2) to understand the risk factors of CDI, and (3) to determine the impact of different diagnostic methods on reported CDI rates.

METHOD

A systematic literature search was conducted using PubMed and Google Scholar database to identify Indian studies reporting the prevalence of CDI. A total of 31 studies, published between 1990 and 2020 were included in the final analysis. A chi-square test was used to determine statistically significant association between prevalence rates, accuracy of different diagnosis methods, and antibiotic usage rates of CDI.

RESULTS

The prevalence of CDI was in the range of 3.4% to 18%, and the difference between regional prevalence of CDI was statistically significant (P < .001). The use of antibiotics, hospital stay, comorbidities, recent surgery, and the use of proton-pump inhibitors was considered as risk factors for the development of CDI. Compared to other regions, the rate of antibiotic usage was significantly higher in North India (P < .001). Among different diagnostic methods, C. difficile detection was significantly higher with enzyme-linked immunosorbent assay (18.02%) versus other multiple testing methods used (P < .001).

CONCLUSION

There is a significant burden of CDI across the country. Further surveillance studies are required to monitor changes in prevalence of CDI, risk factors, and accuracy of diagnosis methods for a better understanding of the disease burden in India.

Clostridioides difficile infection: Incidence and risk factors in a tertiary care facility in Riyadh, Saudi Arabia

BACKGROUND

Significant increase in rates of Clostridioides difficile associated diarrhea (CDI) has been reported globally but there remains a paucity of data from Saudi Arabia.

METHODOLOGY

Prospective hospital-based surveillance for CDI using the Center for Disease Control (CDC) criteria was conducted from June to November 2015 in a tertiary healthcare facility in Riyadh, Saudi Arabia.

RESULTS

During the surveillance period, 106 episodes of CDI were identified among 59 patients in 137,230 patient-days. The incidence of CDI was 3.5 per 10,000 patient days. Of the 106 episodes, 58% (n=61) were new cases, 12% (n=13) were recurrent cases and 30% (n=32) were duplicate cases. Majority of the new cases (n/N=43/61; 70%) were healthcare onset, followed by community onset (21%) and 8% were community-onset healthcare associated. No statistically significant change in trend was observed during the surveillance period. The most prevalent CDI risk factor was use of proton pump inhibitor (PPI) (92%) followed by prolonged use of antibiotics (77%). Pareto-analysis indicated that controlling for PPI use, prolong and multiple antibiotic exposure and prolonged hospitalization results in 80% CDI reduction.

CONCLUSION

The findings indicate a low incidence of CDI. Multicenter studies are needed to elucidate the burden to CDI in the country.

Clostridium difficile-associated Diarrhea in Developing Countries: A Systematic Review and Meta-Analysis

INTRODUCTION

The prevalence of Clostridium difficile infection is rapidly increasing worldwide, but prevalence is difficult to estimate in developing countries where awareness, diagnostic resources, and surveillance protocols are limited. As diarrhea is the hallmark symptom, we conducted a systematic review and meta-analysis to determine the prevalence and incidence of C. difficile infection in patients in these regions who presented with diarrhea.

METHODS

We conducted a systematic literature search of MEDLINE/PubMed, Scopus, and Latin-American and Caribbean Health Sciences Literature databases to identify and analyze data from recent studies providing prevalence or incidence rates of C. difficile-associated diarrhea in developing countries within four regions: Africa-Middle East, developing Asia, Latin America, and China. Our objectives were to determine the current prevalence and incidence density rates of first episodes of C. difficile-associated diarrhea in developing countries.

RESULTS

Within the regions included in our analysis, prevalence of C. difficile infection in patients with diarrhea was 15% (95% CI 13-17%) (including community and hospitalized patients), with no significant difference across regions. The incidence of C. difficile infection in 17 studies including this information was 8.5 per 10,000 patient-days (95% CI 5.83-12.46). Prevalence was significantly higher in hospitalized patients versus community patients (p  = 0.0227).

CONCLUSION

Our prevalence estimate of 15% is concerning; however, low awareness and inconsistent diagnostic and surveillance protocols suggest this is markedly underestimated. Enhanced awareness and management of C. difficile infection in patients with diarrhea, along with improvements in infection control and surveillance practices, should be implemented to reduce prevalence of C. difficile-associated diarrhea in developing countries.

FUNDING

Pfizer Inc.

Incidence, epidemiology and control of Clostridium difficile infection in a tertiary care private hospital in India

Purpose

Clostridium difficile infection (CDI) is a serious healthcare-associated infection (HAI) now being increasingly reported from hospitals across India. However, there is a paucity of data on the incidence of and impact of control measures on CDI in India.

Materials and Methods

This is a retrospective study conducted at a tertiary care hospital in Mumbai from January 2016 to December 2017. All patients with healthcare-onset diarrhoea were tested for C. difficile by glutamate dehydrogenase (GDH)/toxin assay or nucleic acid amplification test (NAAT). CDI was defined as either GDH and toxin positive or NAAT positive. The incidence of CDI was calculated per 1000 patient days. Demographic features of patients with CDI including age, sex, duration of hospitalisation before onset of CDI, antibiotic use and treatment administered were summarised.

Results

A total of 67 patients had CDI in the study period with a mean incidence of 0.2/1000 patient days. A halving of the CDI incidence was seen after intensification of the CDI prevention bundle. The mean age of affected patients was 64 years and CDI occurred at a median duration of 2 weeks after hospitalisation. Eighty-seven per cent of the patients were on antibiotics at the time of diagnosis of CDI. The crude mortality rate was 22%.

Conclusions

CDI is an emerging HAI in India. All hospitals need to set up policies for surveillance, testing, treatment and prevention of CDI based on recent international guidelines and local infrastructure/logistics.

Clostridium difficile infection in low- and middle-human development index countries: a systematic review

OBJECTIVE

To describe the impact and epidemiology of Clostridium difficile infection (CDI) in low- and middle-human development index (LMHDI) countries.

METHOD

Prospectively registered, systematic literature review of existing literature in the PubMed, Ovid and Web of Science databases describing the epidemiology and management of C. difficile in LMHDI countries. Risk factors were compared between studies when available.

RESULTS

Of the 218 abstracts identified after applying search criteria, 25 studies were reviewed in detail. The weighted pooled infection rate among symptomatic non-immunosuppressed inpatients was 15.8% (95% CI 12.1-19.5%) and was 10.1% (95% CI 3.0-17.2%) among symptomatic outpatients. Subgroup analysis of immunosuppressed patient populations revealed pooled infection rates similar to non-immunosuppressed patient populations. Risk factor analysis was infrequently performed.

CONCLUSIONS

While the percentages of patients with CDI in LMHDI countries among the reviewed studies are lower than expected, there remains a paucity of epidemiologic data evaluating burden of C. difficile infection in these settings.

Proton pump inhibitors therapy and risk of Clostridium difficile infection: Systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on proton pump inhibitors (PPIs) therapy and the risk of Clostridium difficile infection (CDI). METHODS We conducted a systematic search of MEDLINE/PubMed and seven other databases through January 1990 to March 2017 for published studies that evaluated the association between PPIs and CDI. Adult case-control and cohort studies providing information on the association between PPI therapy and the development of CDI were included. Pooled odds ratios (ORs) estimates with 95% confidence intervals (CIs) were calculated using the random effect. Heterogeneity was assessed by I2 test and Cochran's Q statistic. Potential publication bias was evaluated via funnel plot, and quality of studies by the Newcastle-Otawa Quality Assessment Scale (NOS).

RESULTS

Fifty-six studies (40 case-control and 16 cohort) involving 356683 patients met the inclusion criteria and were analyzed. Both the overall pooled estimates and subgroup analyses showed increased risk for CDI despite substantial statistical heterogeneity among studies. Meta-analysis of all studies combined showed a significant association between PPI users and the risk of CDI (pooled OR = 1.99, CI: 1.73-2.30, P < 0.001) as compared with non-users. The association remained significant in subgroup analyses: by design-case-control (OR = 2.00, CI: 1.68-2.38, P < 0.0001), and cohort (OR = 1.98, CI: 1.51-2.59, P < 0.0001); adjusted (OR = 1.95, CI: 1.67-2.27, P < 0.0001) and unadjusted (OR = 2.02, CI: 1.41-2.91, P < 0.0001); unicenter (OR = 2.18, CI: 1.72-2.75, P < 0.0001) and multicenter (OR = 1.82, CI: 1.51-2.19, P < 0.0001); age ≥ 65 years (OR = 1.93, CI: 1.40-2.68, P < 0.0001) and < 65 years (OR = 2.06, CI: 1.11-3.81, P < 0.01). No significant differences were found in subgroup analyses (test for heterogeneity): P = 0.93 for case-control vs cohort, P = 0.85 for adjusted vs unadjusted, P = 0.24 for unicenter vs multicenter, P = 0.86 for age ≥ 65 years and < 65 years. There was significant heterogeneity across studies (I2 = 85.4%, P < 0.001) as well as evidence of publication bias (funnel plot asymmetry test, P = 0.002).

CONCLUSION

This meta-analysis provides further evidence that PPI use is associated with an increased risk for development of CDI. Further high-quality, prospective studies are needed to assess whether this association is causal.

Nagging Presence of Clostridium difficile Associated Diarrhoea in North India

Introduction

Clostridium Difficile Associated Diarrhoea (CDAD) is a significant cause of morbidity in hospitalised patients worldwide. The data on clinical epidemiology of this disease in Indian subcontinent is scarce.

Aim

To evaluate the risk factors and clinical course of patients with CDAD.

Materials and Methods

A cross-sectional study was planned at our tertiary care centre, All India Institute of Medical Sciences, whereby, all patients who had nosocomial diarrhea between 2010 and 2014 were included in the study. Their clinical and laboratory profile were recorded using structured questionnaire and their stool samples were subjected to ELISA for detection of toxins A and B (Premier toxins A and B). Those patients who had toxins A and B in their stool samples were diagnosed as CDAD. The clinical and laboratory profile of CDAD patients were further analysed.

Results

A total of 791 patients with nosocomial diarrhea were included in this study. CDAD was diagnosed in a total of 48(6%) patients. The year wise breakdown of the positive patients is as follows: 7/135 (5.2%), 4/156 (2.6%), 5/141 (3.5%), 9/193 (4.7%) and 23/166 (13.8%), respectively. A total of 16/48 (33.3%) of CDAD cases belonged to the age group of 51-60 years. Malignancy (n=15, 31.25%) was the most common underlying pathological condition. All the patients had a history of antibiotic intake. Most common antibiotic used in the patients of CDAD was third generation cephalosporins (n=27, 56.25%). The use of clindamycin, carbapenems and colistin increased in the year 2014. Mean duration of hospital stay was 9.8 days. Diarrhoea was associated with fever in 50% of the patients while abdominal pain was seen in 39.6% of the patients.

Conclusion

The control of Clostridium difficile infection suffers from the rampant use of higher antibiotics. There is a need for proper implementation of antimicrobial stewardship programmes and better hospital infection control to stop the transmission of this nagging bug.

The emergence of Clostridium difficile infection in Asia: A systematic review and meta-analysis of incidence and impact

Background

Clostridium difficile infection (CDI) is the most common healthcare associated infection and is highly prevalent in Europe and North America. Limited data is available on the prevalence of CDI in Asia. However, secular increases in prevalence of risk factors for CDI suggest that it may be emerging as a major cause of morbidity, highlighting the urgent need for a systematic study of the prevalence of CDI in Asia.

Methods

We systematically searched PubMed/Medline and Embase for publications from Asia between 2000–16 examining prevalence of CDI. A random-effects meta-analysis was performed to calculate the pooled prevalence of CDI in Asia and to identify subgroups and regions at high risk.

Results

Our meta-analysis included 51 studies from throughout Asia including 37,663 patients at risk among whom confirmed CDI was found in 4,343 patients. The pooled proportion of confirmed CDI among all patients with diarrhea was 14.8% with a higher prevalence in East Asia (19.5%), compared with South Asia (10.5%) or the Middle East (11.1%). There were an estimated 5.3 episodes of CDI per 10,000 patient days, similar to rates reported from Europe and North America. Infections due to hypervirulent strains were rare. CDI-related mortality was 8.9%.

Conclusions

In a meta-analysis of 51 studies, we observed similar rates of CDI in Asia in comparison to Europe and North America. Increased awareness and improved surveillance of Clostridium difficile is essential to reduce incidence and morbidity.

Clostridium difficile infection: a worldwide disease

Clostridium difficile, an anaerobic toxigenic bacterium, causes a severe infectious colitis that leads to significant morbidity and mortality worldwide. Both enhanced bacterial toxins and diminished host immune response contribute to symptomatic disease. C. difficile has been a well-established pathogen in North America and Europe for decades, but is just emerging in Asia. This article reviews the epidemiology, microbiology, pathophysiology, and clinical management of C. difficile. Prompt recognition of C. difficile is necessary to implement appropriate infection control practices.