Asymptomatic Clostridium difficile colonization in two Australian tertiary hospitals, 2012-2014: prospective, repeated cross-sectional study

Microbial Colonization and Associated Factors in Indwelling Urinary Catheters: A Cross-Sectional Study

This study aimed to determine microbial colonization in indwelling urinary catheters (UCs) and identify patient-specific risk factors associated with this colonization. This cross-sectional study involved 61 hospitalized intensive care unit patients with indwelling UCs. Bacterial colonization and susceptibility were assessed in the indwelling UCs from the second day onwards following urinary catheterization. The average duration of catheterization was 13.62 ± 13.72 days. Colonization of 10⁵ CFU/mL and above was determined in all indwelling UCs from the second day of catheterization onwards. The catheter was colonized by the following microorganism species: Pseudomonas aeruginosa, Acinetobacter baumannii, Proteus mirabilis, and Staphylococcus aureus. 47.9% of clinical isolates showed multi-drug resistance (MDR). Clinical isolates did not show significant differences based on patient variables such as age, Body Mass Index, and duration of urinary catheterization (p > 0.05). There was a weak correlation (rs:≤ 0.206; p > 0.05) between the species of clinical isolates and patient laboratory variables. Colonization was determined in all indwelling UCs, with nearly half of isolates exhibiting MDR. These findings highlight the urgent need for improved strategies to manage and prevent catheter-associated infections, particularly in high-risk patient populations.

Abundant geographical divergence of Clostridioides difficile infection in China: a prospective multicenter cross-sectional study

Clostridioides difficile is the predominant pathogen in hospital-acquired infections and antibiotic-associated diarrhea. Dedicated networks and annual reports for C. difficile surveillance have been established in Europe and North America, however the extensive investigation on the prevalence of C. difficile infection (CDI) in China is limited. In this study, 1528 patients with diarrhea were recruited from seven geographically representative regions of China between July 2021 and July 2022. The positivity rate of toxigenic C. difficile using real-time fluorescence quantitative PCR test of feces was 10.2% (156/1528), and 125 (8.2%, 125/1528) strains were successfully isolated. The isolates from different geographical areas had divergent characteristics after multilocus sequence typing, toxin gene profiling, and antimicrobial susceptibility testing. No isolate from clade 2 were found, and clade 1 was still the main clade for these clinical isolates. Interestingly, clade 4, especially ST37, previously known as the characteristic type of China, showed a strong geographical divergence. Clade 3, although rare in China, has been detected in Hainan and Sichuan provinces. Most C. difficile isolates (76.8%, 96/125) were toxigenic. Clindamycin, erythromycin, and moxifloxacin were the top three antibiotics to which resistance was observed, with resistance rates of 81.3%, 63.6%, and 24.0%, respectively. Furthermore, 34 (27.2%, 34/125) multidrug-resistant (MDR) strains were identified. All the strains were sensitive to metronidazole, vancomycin, and meropenem. The genotype of C. difficile varies greatly among the different geographical regions in China, and new types are constantly emerging. Therefore, comprehensive, longitudinal, and standardized surveillance of C. difficile infections is needed in China, covering typical geographical areas.

Heterogeneity of Clostridioides difficile asymptomatic colonization prevalence: a systematic review and meta-analysis

BACKGROUND

Asymptomatic carriers significantly influence the transmission dynamics of C. difficile. This study aimed to assess the prevalence of toxigenic C. difficile asymptomatic colonization (tCDAC) and investigate its heterogeneity across different populations. We searched MEDLINE, Web of Science, and Scopus for articles published between 2000 and 2023 on tCDAC. Studies including asymptomatic adults with laboratory-confirmed tCDAC were eligible. We performed a random-effects meta-analysis to estimate the pooled prevalence by clinical characteristics, settings, and geographic areas. In addition, we used outlier analyses and meta-regression to explore sources of prevalence variability.

RESULTS

Fifty-one studies involving 39,447 patients were included. The tCDAC prevalence ranged from 0.5 to 51.5%. Among pooled estimates, a high prevalence was observed in patients with cystic fibrosis, outbreak settings, and cancer patients, whereas the lowest rates were found in healthy individuals and healthcare workers. Similar colonization rates were observed between admitted and hospitalized patients. Our meta-regression analysis revealed lower rates in healthy individuals and higher rates in cystic fibrosis patients and studies from North America. Additionally, compared with that among healthy individuals, the prevalence significantly increased by 15-47% among different populations and settings.

CONCLUSION

Our study revealed that tCDAC is a common phenomenon. We found high prevalence estimates that showed significant variability across populations. This heterogeneity could be partially explained by population characteristics and settings, supporting their role in the pathogenesis and burden of this disease. This highlights the need to identify high-risk groups to improve infection control strategies, decrease transmission dynamics, and better understand the natural history of this disease.

Clostridioides difficile colonization and infection in a cohort of Australian adults with cystic fibrosis

BACKGROUND

Little is known about Clostridioides difficile infection (CDI) in patients with cystic fibrosis (CF). The aim of this study was to investigate the prevalence, molecular epidemiology and risk factors for CDI in asymptomatic and symptomatic adults with CF in Western Australia.

METHODS

Faecal samples from symptomatic and asymptomatic patients were prospectively collected and tested for the presence of C. difficile by toxigenic culture. Ribotyping was performed by established protocols. Logistic regression analysis was performed to analyse the risk factors for C. difficile colonization and infection. Extensive environmental sampling was performed within the CF clinic in Perth.

RESULTS

The prevalence rates of asymptomatic toxigenic and non-toxigenic C. difficile colonization were 30% (14/46 patients) and 24% (11/46 patients), respectively. Fifteen ribotypes (RTs) of C. difficile were identified, of which non-toxigenic RT 039 was the most common. Among the symptomatic patients, the prevalence of toxigenic CDI was 33% (11/33 patients). Impaired glucose tolerance/diabetes mellitus and duration of intravenous antibiotic use in the past 12 months were significantly associated with increased risk of asymptomatic toxigenic C. difficile carriage and CDI. A trend towards higher CF transmembrane conductance regulator modulator treatment was observed in the CDI group. Extensive environmental sampling showed no evidence of toxigenic C. difficile contamination within the CF clinic.

CONCLUSIONS

A high prevalence of asymptomatic carriage of toxigenic C. difficile was observed in adults with CF, comparable with that observed in the symptomatic CF population. There was no evidence of direct person-to-person transmission.

Risk factors for Clostridioides difficile colonization among hospitalized adults: A meta-analysis and systematic review

OBJECTIVE

To identify risk factors for asymptomatic Clostridioides difficile colonization among hospitalized adults utilizing a meta-analysis, which may enable early identification of colonized patients at risk of spreading C. difficile.

DESIGN

Meta-analysis and systematic review.

METHODS

We systematically searched MEDLINE, Scopus, Web of Science, and EMBASE from January 1, 1975, to February 15, 2020, for articles related to C. difficile colonization among hospitalized adults. Studies with multivariable analyses evaluating risk factors for asymptomatic colonization were eligible.

RESULTS

Among 5,506 studies identified in the search, 19 studies met the inclusion criteria. Included studies reported 20,334 adult patients of whom 1,588 were asymptomatically colonized with C. difficile. Factors associated with an increased risk of colonization were hospitalization in the previous 6 months (OR, 2.18; 95% CI, 1.86-2.56; P < .001), use of gastric acid suppression therapy within the previous 8 weeks (OR, 1.42; 95% CI, 1.17-1.73; P < .001), tube feeding (OR, 2.02; 95% CI, 1.06-3.85; P = .03), and corticosteroid use in the previous 8 weeks (OR, 1.58; 95% CI, 1.14-2.17; P = .006). Receipt of antibiotics in the previous 3 months (OR, 1.37; 95% CI, 0.94-2.01; P = .10) was not associated with statistically significant effects on risk of colonization.

CONCLUSIONS

C. difficile colonization was significantly associated with previous hospitalization, gastric acid suppression, tube feeding, and corticosteroid use. Recognition of these risk factors may assist in identifying asymptomatic carriers of C. difficile and taking appropriate measures to reduce transmission.

From Nursery to Nursing Home: Emerging Concepts in Clostridioides difficile Pathogenesis

Clostridioides difficile is a Gram-positive, spore-forming, anaerobic bacterium that infects the human gastrointestinal tract, causing a wide range of disorders that vary in severity from mild diarrhea to toxic megacolon and/or death. Over the past decade, incidence, severity, and costs associated with C. difficile infection (CDI) have increased dramatically in both the pediatric and adult populations. The factors driving this rapidly evolving epidemiology remain largely unknown but are likely due in part to previously unappreciated host, microbiota, and environmental factors. In this review, we will cover the risks and challenges of CDI in adult and pediatric populations and examine asymptomatic colonization in infants. We will also discuss the emerging role of diet, pharmaceutical drugs, and pathogen-microbiota interactions in C. difficile pathogenesis, as well as the impact of host-microbiota interactions in the manifestation of C. difficile-associated disease. Finally, we highlight new areas of research and novel strategies that may shed light on this complex infection and provide insights into the future of microbiota-based therapeutics for CDI.

Patient Outcomes With Prevented vs Negative Clostridioides difficile Tests Using a Computerized Clinical Decision Support Tool

Background

Overtesting and overdiagnosis of Clostridioides difficile infection are suspected to be common. Reducing inappropriate testing through interventions designed to promote evidence-based diagnostic testing (ie, diagnostic stewardship) may improve C. difficile test utilization. However, the safety of these interventions is not well understood despite the potential risk for missed or delayed diagnoses.

Methods

This retrospective case-control study examined the outcomes of patients admitted to the University of Virginia Medical Center following introduction of a computerized clinical decision support tool without hard-stops designed to reduce inappropriate tests. Outcomes were compared between patients with a prevented C. difficile nucleic acid amplification test and those with a negative result. Chart reviews were performed for patients with a subsequent positive within 7 days, as well as those patients who received C. difficile-active antibiotics after implementation of the computerized clinical decision support tool.

Results

Multivariate analysis of 637 cases (490 negative, 147 prevented) showed that a prevented test was not significantly associated with the primary composite outcome (inpatient mortality or intensive care unit transfer) compared with a negative test (adjusted odds ratio, 0.912; P = .747). Fifty-four of 147 (37%) prevented tests were followed by a completed test within 7 days; 11 of these results were positive, resulting in a potential delay in diagnosis. Individual case reviews found that either clinical changes warranted the delay in testing or no adverse events occurred attributable to C. difficile infection. C. difficile treatment without a positive test was not identified.

Conclusions

Diagnostic stewardship of C. difficile testing using computerized clinical decision support may be both safe and effective for reducing inappropriate inpatient testing.

Clostridioides difficile infection in the Asia-Pacific region

Clostridioides difficile causes healthcare-related diarrhoea in high-income countries. Highly resistant spores persist in healthcare facilities, primarily infecting patients who have recently received antimicrobials. C. difficile infection (CDI) has been studied in detail in North America and Europe; however, the epidemiology of CDI elsewhere, including the Asia-Pacific region, is largely unknown. A survey of CDI was performed in 13 Asia-Pacific countries. Epidemiological data on 600 cases were collected and molecular typing undertaken on 414 C. difficile isolates. Healthcare facility-associated CDI comprised 53.6% of cases, while community-associated CDI was 16.5%. The median age of cases was 63.0 years and 45.3% were female, 77.5% had used antibiotics in the previous 8 weeks, most frequently third-generation cephalosporins (31.7%), and 47.3% had used proton pump inhibitors. Recurrence (9.1%) and mortality (5.2%) rates were low, while complications including colitis or pseudomembranous colitis (13.8%), colectomy (0.4%), and toxic megacolon (0.2%) were uncommon. Common C. difficile strains were ribotypes 017 (16.7%), 014/020 (11.1%) and 018 (9.9%), with wide variation between countries. Binary toxin-positive strains of C. difficile were detected rarely. Overall, disease severity appeared mild, and mortality and recurrence were low. Continued education about, and surveillance of, CDI in Asia are required to reduce the burden of disease.

Detection and Isolation of Clostridium difficile Asymptomatic Carriers During Clostridium difficile Infection Outbreaks: An Exploratory Study

During 4 Clostridium difficile infection outbreaks, unit-wide screening of 114 patients led to detection and isolation of 15 (13%) C. difficile asymptomatic carriers. Carriage prevalence varied between outbreaks, from 0% to 29% (P = .004). Isolating carriers was not associated with significantly shorter outbreak durations, compared with historical controls.

Spatial clusters of Clostridium difficile infection and an association with neighbourhood socio-economic disadvantage in the Australian Capital Territory, 2004-2014

BACKGROUND

In Australia, rates of Clostridium difficile infection (CDI) in all States and Territories have increased significantly since mid-2011, with rates of infection increasing faster in the community setting than within hospitals. Knowledge about the risk factors for CDI is essential to determine the risk of community outbreaks of CDI and to design interventions that reduce those risks.

METHODS

We examine the role of neighbourhood socio-economic disadvantage, demography and testing practices on spatial patterns in CDI incidence in the Australian Capital Territory (ACT). Data on all tests conducted for CDI, including postcode of residence, were obtained from January 2004-December 2014. Distribution of age groups and the neighbourhood Index of Relative Socio-economic Advantage Disadvantage (IRSAD) were obtained from the Australian Bureau of Statistics 2011 National Census data. A Bayesian spatial conditional autoregressive model was fitted at the postcode level to quantify the relationship between CDI and socio-demographic factors. To identify CDI hotspots, exceedance probabilities were set at a threshold of twice the estimated relative risk.

RESULTS

After controlling for spatial patterns in testing practices, area-level socio-economic advantage (IRSAD) (RR = 0.74, 95% CI 0.57, 0.94) was inversely associated with CDI. Three postcodes had a high probability (0.8-1.0) of excess risk of diagnosed CDI.

CONCLUSION

We demonstrate geographic variations in CDI in the ACT with a positive association of CDI with neighbourhood socioeconomic disadvantage and identify areas with a high probability of elevated risk compared with surrounding communities. These findings provide further evidence to inform a targeted response to reduce CDI risk.

Microbiological evaluation of the ability of the DEKO-190 Washer/Disinfector to remove Clostridium difficile spores from bedpan surfaces

BACKGROUND

Clostridium difficile is a major nosocomial pathogen causing mild diarrhoea to life-threatening pseudomembranous colitis, and its spores frequently contaminate hospital environments and equipment. Washer/Disinfectors (WDs) are commonly used to clean and decontaminate soiled equipment in health care facilities. This study aimed to evaluate the effectiveness of the DEKO-190 WD in removing C. difficile spores from bedpans.

METHODS

Plastic carriers were inoculated with suspensions of C. difficile spores in autoclaved (sterile) human faeces. The carriers were then taped to a sterile plastic bedpan which was subjected to short, long or intensive wash cycles in the WD using one of two test detergents: Formula A (generic) and Formula B (highly alkaline). Mean log₁₀ reductions in spores were calculated for each wash cycle.

RESULTS

Mean log₁₀ reductions were 3.21(SEM ± 0.20) and 2.82 (±0.13) for Formula A and B, respectively, for the short cycle. The mean log₁₀ reductions using the long wash cycle were 3.65 (±0.44) using Formula A and 5.30 (±0.43) using Formula B, while log₁₀ reductions were 3.37 (±0.58) (Formula A) and 4.64 (±0.47) (Formula B) for the intensive cycle. Washing with the DEKO-190 significantly reduced spore concentrations on carrier surfaces on a bedpan. Spore counts were most effectively reduced when carriers were washed on a long or intensive wash cycle using an alkaline detergent.

Seasonality and community interventions in a mathematical model of Clostridium difficile transmission

BACKGROUND

Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated diarrhoea with peak incidence in late winter or early autumn. Although CDI is commonly associated with hospitals, community transmission is important.

AIM

To explore potential drivers of CDI seasonality and the effect of community-based interventions to reduce transmission.

METHODS

A mechanistic compartmental model of C. difficile transmission in a hospital and surrounding community was used to determine the effect of reducing transmission or antibiotic prescriptions in these settings. The model was extended to allow for seasonal antibiotic prescriptions and seasonal transmission.

FINDINGS

Modelling antibiotic seasonality reproduced the seasonality of CDI, including approximate magnitude (13.9-15.1% above annual mean) and timing of peaks (0.7-1.0 months after peak antibiotics). Halving seasonal excess prescriptions reduced the incidence of CDI by 6-18%. Seasonal transmission produced larger seasonal peaks in the prevalence of community colonization (14.8-22.1% above mean) than seasonal antibiotic prescriptions (0.2-1.7% above mean). Reducing transmission from symptomatic or hospitalized patients had little effect on community-acquired CDI, but reducing transmission in the community by ≥7% or transmission from infants by ≥30% eliminated the pathogen. Reducing antibiotic prescription rates led to approximately proportional reductions in infections, but limited reductions in the prevalence of colonization.

CONCLUSION

Seasonal variation in antibiotic prescription rates can account for the observed magnitude and timing of C. difficile seasonality. Even complete prevention of transmission from hospitalized patients or symptomatic patients cannot eliminate the pathogen, but interventions to reduce transmission from community residents or infants could have a large impact on both hospital- and community-acquired infections.

Clostridioides difficile Infection in Chronic Kidney Disease/End-Stage Renal Disease

Clostridioides difficile infection (CDI) is a major health-care burden and increasingly seen in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Increased antibiotic use, alteration in host defenses, and gastric acid suppression are some of the etiologies for increased risk of CDI in these populations. Patients with CKD/ESRD have a higher risk of initial episode, recurrence, and development of severe CDI than those without CKD or ESRD. Diagnosis and management of CDI in patients with CKD/ESRD are similar to that in the general population. The mortality, length of stay, and health-care costs are higher in patients with CDI and CKD/ESRD. Antimicrobial stewardship with reduction in antibiotic use along with infection-control measures such as contact isolation and hand hygiene with soap and water is essential in the control and prevention of CDI in patients with CKD/ESRD.

Clostridium difficile infection in hospitalized patients with COPD in Spain (2001-2015)

BACKGROUND

The objectives of this study were to examine incidence and in-hospital outcomes of Clostridium difficile infection (CDI) among patients with COPD, to compare clinical variables among COPD patients with matched non-COPD patients hospitalized with CDI, and to identify factors associated with in-hospital mortality (IHM) among COPD patients.

METHODS

We performed a retrospective study using the Spanish National Hospital Discharge Database from 2001 to 2015. We included patients aged 40 years or over with a primary or secondary diagnosis of CDI. For each COPD patient, we selected a sex, age, readmission status and year-matched non-COPD patient.

RESULTS

We identified 44,695 patients with CDI (19.36% with COPD). Incidence of CDI has increased significantly from 2001 to 2015 besides COPD status. Incidence was higher in COPD patients than in patients without this disease (IRR 2.24; 95%CI 2.18-2.29). IHM decreased significantly over time in patients without COPD (from 13.98% in 2001-03 to 10.99% in 2013-15), but there were no changes in those with COPD (from 12.93% in 2001-03 to 13.37% in 2013-15). In COPD patients, higher mortality rates were associated with older age, comorbidities, severe CDI, longer length of hospital stay and readmission. Primary diagnosis of CDI was associated with lower IHM in this group of patients (OR 0.66; 95%CI 0.56-0.77) in comparison with secondary diagnosis.

CONCLUSIONS

Incidence of CDI was twice higher in COPD patients than in matched non-COPD controls and is increasing overtime in both groups. Our results suggest that the management of CDI has improved in Spain during the study period.

Sensitivity of Single-Molecule Array Assays for Detection of Clostridium difficile Toxins in Comparison to Conventional Laboratory Testing Algorithms

Guidelines recommend the use of an algorithm for the laboratory diagnosis of Clostridium difficile infection (CDI). Enzyme immunoassays (EIAs) detecting C. difficile toxins cannot be used as standalone tests due to suboptimal sensitivity, and molecular tests suffer from nonspecificity by detecting colonization.

Guidelines recommend the use of an algorithm for the laboratory diagnosis of Clostridium difficile infection (CDI). Enzyme immunoassays (EIAs) detecting C. difficile toxins cannot be used as standalone tests due to suboptimal sensitivity, and molecular tests suffer from nonspecificity by detecting colonization. Sensitive immunoassays have recently been developed to improve and simplify CDI diagnosis. Assays detecting CD toxins have been developed using single-molecule array (SIMOA) technology. SIMOA performance was assessed relative to a laboratory case definition of CDI defined by positive glutamate dehydrogenase (GDH) screen and cell cytotoxicity neutralizing assay (CCNA). Samples were tested with SIMOA assays and a commercial toxin EIA to compare performance, with discrepancy resolution using a commercial nucleic acid-based test and a second cell cytotoxicity assay. The SIMOA toxin A and toxin B assays showed limits of detection of 0.6 and 2.9 pg/ml, respectively, and intra-assay coefficients of variation of less than 10%. The optimal clinical thresholds for the toxin A and toxin B assays were determined to be 22.1 and 18.8 pg/ml, respectively, with resultant sensitivities of 84.8 and 95.5%. In contrast, a high-performing EIA toxin test had a sensitivity of 71.2%. Thus, the SIMOA assays detected toxins in 24% more samples with laboratory-defined CDI than the high performing toxin EIA (95% [63/66] versus 71% [47/66]). This study shows that SIMOA C. difficile toxin assays have a higher sensitivity than currently available toxin EIA and have the potential to improve CDI diagnosis.

[Clostridium difficile in the intensive care unit]

Clostridium difficile infections (CDI) are encountered in about 1-2% of patients in the intensive care unit (ICU) and pose a special challenge to those who provide care. Only little data regarding severity and management of CDI in ICU patients in Europe are available. Extrapolation of results from one patient population to another is often difficult. The comorbidities of those patients often limit the application of general recommendations concerning diagnosis and therapy. In addition, there are a relevant percentage of patients (10-20%) with asymptomatic C. difficile colonization. The relevance for the patient and for the risk of patient to patient infection is not yet fully understood. Based on available data, we give an overview of current challenges in the diagnosis, assessment of disease course, primary management options, and alternatives in special cases and treatment failures of CDI. We also discuss prevention of new CDI in the intensive care unit.

Clostridium difficile Exposures, Colonization, and the Microbiome: Implications for Prevention

New studies have been published regarding the epidemiology of Clostridium difficile in topics such as asymptomatic C. difficile colonization, community-associated C. difficile infection, environmental contamination outside healthcare settings, animal colonization, and the interactions between C. difficile and the gut microbiome. In addition to summarizing these findings, this review offers a perspective on the potential impact of high-throughput sequencing and other potential techniques on the prevention of C. difficile.Infect Control Hosp Epidemiol 2018;39:596-602.

Understanding Clostridium difficile Colonization

Clostridium difficile is the main causative agent of antibiotic-associated and health care-associated infective diarrhea. Recently, there has been growing interest in alternative sources of C. difficile other than patients with Clostridium difficile infection (CDI) and the hospital environment. Notably, the role of C. difficile-colonized patients as a possible source of transmission has received attention. In this review, we present a comprehensive overview of the current understanding of C. difficile colonization. Findings from gut microbiota studies yield more insights into determinants that are important for acquiring or resisting colonization and progression to CDI. In discussions on the prevalence of C. difficile colonization among populations and its associated risk factors, colonized patients at hospital admission merit more attention, as findings from the literature have pointed to their role in both health care-associated transmission of C. difficile and a higher risk of progression to CDI once admitted. C. difficile colonization among patients at admission may have clinical implications, although further research is needed to identify if interventions are beneficial for preventing transmission or overcoming progression to CDI.

Clostridium difficile colonization and infection in patients with hepatic cirrhosis

OBJECTIVE

The aim of this study was to investigate the toxigenic Clostridium difficile colonization (CDC, colonization with toxigenic C. difficile but without symptoms) and C. difficile infection (CDI, active C. difficile infection resulting in disease symptoms) in hepatic cirrhosis patients, identify the risk factors of CDC, and determine the correlation between CDC and CDI.

METHODOLOGY

The strains of toxigenic C. difficile were isolated from patients with hepatic cirrhosis within 48 h after admission, followed by multilocus sequence typing (MLST). Patients were divided into toxigenic CDC group and noncolonized (NC) group according to the colonization. Logistic regression analysis was performed to analyse the risk factors for the CDC. Besides, the CDI incidence was compared between the two groups.

RESULTS

Colonization of toxigenic C. difficile was identified in 104 cases (19.8 %). Eighteen sequence types (STs) were identified, among which ST-3, ST-54, ST-35 and ST-37 were the predominant types. Child-Pugh class C(relative risk, RR, 3.025; 95 % CI: 1.410-6.488), decrease of prothrombin time activity (PTA) (RR 2.180; 95 % CI: 1.368-3.476), decrease of platelet (RR 2.746; 95 % CI: 0.931-8.103) and concurrent hepatic encephalopathy (RR 1.740; 95 % CI: 1.012-2.990) were identified as the risk factors for the hepatic cirrhosis patients with CDC. The CDI incidence in the CDC group was also significantly higher than that of the NC group (26.0 % vs 1.7 %, P<0.001).

CONCLUSION

An carriage rate of 19.8 % was reported in the hepatic cirrhosis patients with C. difficile colonization. Child's class C, decrease of PTA and platelet, and concurrent hepatic encephalopathy were the risk factors for the hepatic cirrhosis patients with C. difficile colonization. Hepatic cirrhosis patients with C. difficile colonization were more susceptible to CDI.

Comparison of Clostridium difficile Ribotypes Circulating in Australian Hospitals and Communities

Clostridium difficile infection (CDI) is becoming less exclusively a health care-associated CDI (HA-CDI). The incidence of community-associated CDI (CA-CDI) has increased over the past few decades. It has been postulated that asymptomatic toxigenic C. difficile (TCD)-colonized patients may play a role in the transfer of C. difficile between the hospital setting and the community. Thus, to investigate the relatedness of C. difficile across the hospital and community settings, we compared the characteristics of symptomatic and asymptomatic host patients and the pathogens from these patients in these two settings over a 3-year period. Two studies were simultaneously conducted; the first study enrolled symptomatic CDI patients from two tertiary care hospitals and the community in two Australian states, while the second study enrolled asymptomatic TCD-colonized patients from the same tertiary care hospitals. A total of 324 patients (96 with HA-CDI, 152 with CA-CDI, and 76 colonized with TCD) were enrolled. The predominant C. difficile ribotypes isolated in the hospital setting corresponded with those isolated in the community, as it was found that for 79% of the C. difficile isolates from hospitals, an isolate with a matching ribotype was isolated in the community, suggesting that transmission between these two settings is occurring. The toxigenic C. difficile strains causing symptomatic infection were similar to those causing asymptomatic infection, and patients exposed to antimicrobials prior to admission were more likely to develop a symptomatic infection (odds ratio, 2.94; 95% confidence interval, 1.20 to 7.14). Our findings suggest that the development of CDI symptoms in a setting without establishment of hospital epidemics with binary toxin-producing C. difficile strains may be driven mainly by host susceptibility and exposure to antimicrobials, rather than by C. difficile strain characteristics.