Hostname: page-component-76d6cb85b7-mgxrv Total loading time: 0 Render date: 2026-07-11T06:55:31.695Z Has data issue: false hasContentIssue false
  • English
  • Français

Impact of Toxigenic Clostridium difficile Colonization on the Risk of Subsequent C. difficile Infection in Intensive Care Unit Patients

Published online by Cambridge University Press:  30 July 2015

Sarah Tschudin-Sutter ,
Karen C. Carroll ,
Pranita D. Tamma ,
Madeleine L. Sudekum ,
Reno Frei ,
Andreas F. Widmer ,
Brandon C. Ellis ,
John Bartlett  and
Trish M. Perl
Sarah Tschudin-Sutter*
Affiliation:
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
Karen C. Carroll
Affiliation:
Division of Medical Microbiology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
Pranita D. Tamma
Affiliation:
Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
Madeleine L. Sudekum
Affiliation:
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Reno Frei
Affiliation:
Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland
Andreas F. Widmer
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
Brandon C. Ellis
Affiliation:
Division of Medical Microbiology, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
John Bartlett
Affiliation:
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Trish M. Perl
Affiliation:
Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
*
Address correspondence to Sarah Tschudin-Sutter, MD, MSc, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland (sarah.tschudin@usb.ch).
Get access Rights & Permissions [Opens in a new window]

Abstract

BACKGROUND

Clostridium difficile infection (CDI) in hospitalized patients is generally attributed to the current stay, but recent studies reveal high C. difficile colonization rates on admission.

OBJECTIVE

To determine the rate of colonization with toxigenic C. difficile among intensive care unit patients upon admission as well as acquired during hospitalization, and the risk of subsequent CDI.

METHODS

Prospective cohort study from April 15 through July 8, 2013. Adults admitted to an intensive care unit within 48 hours of admission to the Johns Hopkins Hospital, Baltimore, Maryland, were screened for colonization with toxigenic C. difficile. The primary outcome was risk of developing CDI.

RESULTS

Among 542 patients, 17 (3.1%) were colonized with toxigenic C. difficile on admission and an additional 3 patients were found to be colonized during hospitalization. Both colonization with toxigenic C. difficile on admission and colonization during hospitalization were associated with an increased risk for development of CDI (relative risk, 10.29 [95% CI, 2.24–47.40], P=.003; and 15.66 [4.01–61.08], P<.001, respectively). Using multivariable analysis, colonization on admission and colonization during hospitalization were independent predictors of CDI (relative risk, 8.62 [95% CI, 1.48–50.25], P=.017; and 10.93 [1.49–80.20], P=.019, respectively), while adjusting for potential confounders.

CONCLUSIONS

In intensive care unit patients, colonization with toxigenic C. difficile is an independent risk factor for development of subsequent CDI. Further studies are needed to identify populations with higher toxigenic C. difficile colonization rates possibly benefiting from screening or avoidance of agents known to promote CDI.

Infect. Control Hosp. Epidemiol. 2015;36(11):1324–1329

Information

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 36 , Issue 11 , November 2015 , pp. 1324 - 1329
Copyright
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

Footnotes

Presented in part: 24th European Congress of Clinical Microbiology and Infectious Diseases; Barcelona, Spain; May 11, 2014 (Abstract P0773).

References

REFERENCES

1. Kyne, L, Hamel, MB, Polavaram, R, Kelly, CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile . Clin Infect Dis 2002;34:346–353.CrossRefGoogle ScholarPubMed
2. Magill, SS, Edwards, JR, Bamberg, W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:1198–1208.CrossRefGoogle ScholarPubMed
3. Micek, ST, Schramm, G, Morrow, L, et al. Clostridium difficile infection: a multicenter study of epidemiology and outcomes in mechanically ventilated patients. Crit Care Med 2013;41:1968–1975.CrossRefGoogle ScholarPubMed
4. McDonald, LC. Vital signs: preventing Clostridium difficile infections. MMWR Morb Mortal Wkly Rep 2012;61:157–162.Google Scholar
5. Cohen, SH, Gerding, DN, Johnson, S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31:431–455.CrossRefGoogle Scholar
6. Deutsches Institut für Normung EN. Chemische Desinfektionsmittel und Antiseptika. Hygienische Händedesinfektion. Prüfverfahren und Anforderungen (Phase 2/Stufe 2). 1997.Google Scholar
7. Stubbs, SL, Brazier, JS, O'Neill, GL, Duerden, BI. PCR targeted to the 16S-23S rRNA gene intergenic spacer region of Clostridium difficile and construction of a library consisting of 116 different PCR ribotypes. J Clin Microbiol 1999;37:461–463.CrossRefGoogle Scholar
8. Zou, G. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004;159:702–706.CrossRefGoogle ScholarPubMed
9. Hung, YP, Tsai, PJ, Hung, KH, et al. Impact of toxigenic Clostridium difficile colonization and infection among hospitalized adults at a district hospital in southern Taiwan. PLoS One 2012;7:e42415.CrossRefGoogle Scholar
10. Alasmari, F, Seiler, SM, Hink, T, Burnham, CA, Dubberke, ER. Prevalence and risk factors for asymptomatic Clostridium difficile carriage. Clin Infect Dis 2014;59:216–222.CrossRefGoogle ScholarPubMed
11. Loo, VG, Bourgault, AM, Poirier, L, et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med 2011;365:1693–1703.CrossRefGoogle ScholarPubMed
12. Curry, SR, Schlackman, JL, Hamilton, TM, et al. Perirectal swab surveillance for Clostridium difficile by use of selective broth preamplification and real-time PCR detection of tcdB. J Clin Microbiol 2011;49:3788–3793.CrossRefGoogle ScholarPubMed
13. McFarland, LV, Mulligan, ME, Kwok, RY, Stamm, WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204–210.CrossRefGoogle ScholarPubMed
14. Brazier, JS, Fitzgerald, TC, Hosein, I, et al. Screening for carriage and nosocomial acquisition of Clostridium difficile by culture: a study of 284 admissions of elderly patients to six general hospitals in Wales. J Hosp Infect 1999;43:317–319.CrossRefGoogle ScholarPubMed
15. Hutin, Y, Casin, I, Lesprit, P, et al. Prevalence of and risk factors for Clostridium difficile colonization at admission to an infectious diseases ward. Clin Infect Dis 1997;24:920–924.CrossRefGoogle Scholar
16. Kyne, L, Warny, M, Qamar, A, Kelly, CP. Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med 2000;342:390–397.CrossRefGoogle ScholarPubMed
17. Leekha, S, Aronhalt, KC, Sloan, LM, Patel, R, Orenstein, R. Asymptomatic Clostridium difficile colonization in a tertiary care hospital: admission prevalence and risk factors. Am J Infect Control 2013;41:390–393.CrossRefGoogle Scholar
18. Samore, MH, DeGirolami, PC, Tlucko, A, Lichtenberg, DA, Melvin, ZA, Karchmer, AW. Clostridium difficile colonization and diarrhea at a tertiary care hospital. Clin Infect Dis 1994;18:181–187.CrossRefGoogle ScholarPubMed
19. Marciniak, C, Chen, D, Stein, AC, Semik, PE. Prevalence of Clostridium difficile colonization at admission to rehabilitation. Arch Phys Med Rehabil 2006;87:1086–1090.CrossRefGoogle ScholarPubMed
20. Khanna, S, Pardi, DS, Aronson, SL, et al. The epidemiology of community-acquired Clostridium difficile infection: a population-based study. Am J Gastroenterol 2012;107:89–95.CrossRefGoogle ScholarPubMed
21. Severe Clostridium difficile–associated disease in populations previously at low risk—four states, 2005. MMWR Morb Mortal Wkly Rep 2005;54:1201–1205.Google Scholar
22. Surveillance for community-associated Clostridium difficile—Connecticut, 2006. MMWR Morb Mortal Wkly Rep 2008;57:340–343.Google Scholar
23. Garey, KW, Jiang, ZD, Yadav, Y, Mullins, B, Wong, K, Dupont, HL. Peripartum Clostridium difficile infection: case series and review of the literature. Am J Obstet Gynecol 2008;199:332–337.CrossRefGoogle ScholarPubMed
24. Rouphael, NG, O'Donnell, JA, Bhatnagar, J, et al. Clostridium difficile–associated diarrhea: an emerging threat to pregnant women. Am J Obstet Gynecol 2008;198:635.e1–636.CrossRefGoogle ScholarPubMed
25. Benson, L, Song, X, Campos, J, Singh, N. Changing epidemiology of Clostridium difficile–associated disease in children. Infect Control Hosp Epidemiol 2007;28:1233–1235.CrossRefGoogle ScholarPubMed
26. Hoover, DG, Rodriguez-Palacios, A. Transmission of Clostridium difficile in foods. Infect Dis Clin North Am 2013;27:675–685.CrossRefGoogle ScholarPubMed
27. Deshpande, A, Pant, C, Pasupuleti, V, et al. Association between proton pump inhibitor therapy and Clostridium difficile infection in a meta-analysis. Clin Gastroenterol Hepatol 2012;10:225–233.CrossRefGoogle ScholarPubMed
28. Dubberke, ER, Reske, KA, Olsen, MA, et al. Evaluation of Clostridium difficile–associated disease pressure as a risk factor for C. difficile–associated disease. Arch Intern Med 2007;167:1092–1097.CrossRefGoogle ScholarPubMed
29. Shim, JK, Johnson, S, Samore, MH, Bliss, DZ, Gerding, DN. Primary symptomless colonisation by Clostridium difficile and decreased risk of subsequent diarrhoea. Lancet 1998;351:633–636.CrossRefGoogle ScholarPubMed
30. Kyne, L, Warny, M, Qamar, A, Kelly, CP. Association between antibody response to toxin A and protection against recurrent Clostridium difficile diarrhoea. Lancet 2001;357:189–193.CrossRefGoogle ScholarPubMed
31. Lowy, I, Molrine, DC, Leav, BA, et al. Treatment with monoclonal antibodies against Clostridium difficile toxins. N Engl J Med 2010;362:197–205.CrossRefGoogle ScholarPubMed