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A Large Outbreak of Clostridium difficile–Associated Disease with an Unexpected Proportion of Deaths and Colectomies at a Teaching Hospital Following Increased Fluoroquinolone Use

  • Carlene A. Muto (a1) (a2), Marian Pokrywka (a1), Kathleen Shutt (a2), Aaron B. Mendelsohn (a3), Kathy Nouri (a1), Kathy Posey (a1), Terri Roberts (a1), Karen Croyle (a1), Sharon Krystoflak (a1), Sujata Patel-Brown (a2), A. William Pasculle (a4) (a5), David L. Paterson (a2), Melissa Saul (a6) and Lee H. Harrison (a2)...
Abstract
AbstractBackground and Objective:

Fluoroquinolones have not been frequently implicated as a cause of Clostridium difficile outbreaks. Nosocomial C. difficile infections increased from 2.7 to 6.8 cases per 1,000 discharges (P < .001). During the first 2 years of the outbreak, there were 253 nosocomial C. difficile infections; of these, 26 resulted in colectomy and 18 resulted in death. We conducted an investigation of a large C. difficile outbreak in our hospital to identify risk factors and characterize the outbreak.

Methods:

A retrospective case-control study of case-patients with C. difficile infection from January 2000 through April 2001 and control-patients matched by date of hospital admission, type of medical service, and length of stay; an analysis of inpatient antibiotic use; and antibiotic susceptibility testing and molecular subtyping of isolates were performed.

Results:

On logistic regression analysis, clindamycin (odds ratio [OR], 4.8; 95% confidence interval [CI95], 1.9-12.0), ceftriaxone (OR, 5.4; CI95, 1.8-15.8), and levofloxacin (OR, 2.0; CI95, 1.2-3.3) were independently associated with infection. The etiologic fractions for these three agents were 10.0%, 6.7%, and 30.8%, respectively. Fluoroquinolone use increased before the onset of the outbreak (P < .001); 59% of case-patients and 41% of control-patients had received this antibiotic class. The outbreak was polyclonal, although 52% of isolates belonged to two highly related molecular subtypes.

Conclusions:

Exposure to levofloxacin was an independent risk factor for C. difficile-associated diarrhea and appeared to contribute substantially to the outbreak. Restricted use of levofloxacin and the other implicated antibiotics may be required to control the outbreak.

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Corresponding author
University of Pittsburgh Medical Center (UPMC-P), 1215 Kaufmann Building, Pittsburgh, PA 15213mutoca@msx.upmc.edu
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, , , . ;:–.1. DN Gerding MM Olson LR Peterson et al. diarrhea and colitis in adults: a prospective case-controlled epidemiologic studyClostridium difficile-associated Arch Intern Med 1986 146 95100

. . ;:–.2. JG Bartlett Antibiotic-associated diarrhea Clin Infect Dis 1992 15 573581

, . . ;:–.3. R Fekety AB Shah Diagnosis and treatment of colitisClostridium difficile JAMA 1993 269 7175

, , , . . ;:–.4. LV McFarland ME Mulligan RY Kwok WE Stamm Nosocomial acquisition of infectionClostridium difficile N Engl J Med 1989 320 204210

, , , , , . . ;:–.5. S Johnson CR Clabots FV Linn MM Olson LR Peterson DN Gerding Nosocomial colonisation and diseaseClostridium difficile Lancet 1990 336 97100

, , , . ;:–.7. K Lai ZS Melvin MJ Menard et al. diarrhea: epidemiology, risk factors, and infection controlClostridium difficile-associated Infect Control Hosp Epidemiol 1997 18 628632

, , , , . . ;:–.8. SM Pear TH Williamson KM Bettin DN Gerding JN Galgiani Decrease in nosocomial diarrhea by restricting clindamycin useClostridium difficile-associated Ann Intern Med 1994 120 272277

, , , . . ;:–.9. MS Drapin MG Worthington TW Chang SA Razvi colitis mimicking acute peritonitisClostridium difficile Arch Surg 1985 120 13211322

, , . . ;:–.10. MS Rubin LE Bodenstein KC Kent Severe colitisClostridium difficile Dis Colon Rectum 1995 38 350354

, , , . . ;:–.11. L Kyne MB Hamel R Polavaram CP Kelly Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile Clin Infect Dis 2002 34 346353

. . ;:–.13. DN Gerding Disease associated with infectionClostridium difficile Ann Intern Med 1989 110 255257

. ;:–.15. RK Zimmerman Risk factors for cytotoxin-positive diarrhea after control for horizontal transmissionClostridium difficile Infect Control Hosp Epidemiol 1991 12 96100

, , . . ;:–.16. LV McFarland CM Surawicz WE Stamm Risk factors for carriage and diarrhea in a cohort of hospitalized patientsClostridium difficileC. difficile-associated J Infect Dis 1990 162 678684

, , . . ;:–.19. PW Watanakunakorn C Watanakunakorn J Hazy Risk factors associated with diarrhea in hospitalized adult patients: a case-control study—sucralfate ingestion is not a negative risk factorClostridium difficile Infect Control Hosp Epidemiol 1996 17 232235

. . ;:–.21. FJ Tedesco Ampicillin-associated diarrhea: a prospective study American Journal of Digestive Diseases 1975 20 295297

, , . . ;(suppl):–.22. MJ Gurwith HR Rabin K Love Diarrhea associated with clindamycin and ampicillin therapy: preliminary results of a cooperative study J Infect Dis 1977 135 S104S110

, , , . ;:–.23. J Wiström SR Norrby EB Myhre et al.Frequency of antibiotic-associated diarrhoea in 2,462 antibiotic-treated hospitalized patients: a prospective study J Antimicrob Chemother 2001 47 4350

, , . . ;:–.27. RJ Hillman R Gopal RJ Harris Ciprofloxacin as a cause of diarrhea in an HIV antibody positive patientClostridium difficile-associated J Infect 1990 21 205207

, . . ;:.28. DB Cain ME O'Conner Pseudomembranous colitis associated with ciprofloxacin Lancet 1990 336 946

, , . . ;:.29. CJ Bates MH Wilcox RC Spencer Ciprofloxacin and infectionClostridium difficile Lancet 1990 336 1193

. . ;:–.30. RV Loge Oral fluoroquinolone therapy for enterocolitisClostridium difficile JAMA 1989 261 20632064

, , , . ;:–.31. R Gaynes D Rimland E Killum et al.Outbreak of infection in a long-term care facility: association with gatifloxacin useClostridium difficile Clin Infect Dis 2004 38 640645

, , , . . ;:–.32. ME McCusker AD Harris E Perencevich M-C Roghmann Fluoroquinolone use and diarrheaClostridium difficile-associatei Emerg Infect Dis 2003 9 730733

, , , . ;:–.33. RM Dallai BG Harbrecht AJ Boujoukas et al.Fulminant an underappreciated and increasing cause of death and complicationsClostridium difficile: Ann Surg 2002 235 363372

, Hospital Infection Control Practices Advisory Committee. . ;:–.35. JS Garner Guideline for isolation precautions in hospitals Infect Control Hosp Epidemiol 1996 17 5380

36. RJ Yount , JK Vries , CD Councill . The Medical Archival Retrieval system: an information retrieval system based on distributed parallel processing. Information Processing and Management 1991;27:111.

, , , , . . ;:–.38. LS Mundy CJ Shanholtzer KE Willard DE Gerding LR Peterson Laboratory detection of : a comparison of media and incubation systemsClostridium difficile Am J Clin Pathol 1995 103 5256

, , . . ;:–.43. CR Clabots LR Peterson DN Gerding Characterization of a nosocomial outbreak by using plasmid profile typing and clindamycin susceptibility testingClostridium difficile J Infect Dis 1988 158 731736

, , , . . ;:–.44. MH Wilcox W Fawley J Freeman J Brayson In vitro activity of new generation fluoroquinolones against genotypically distinct and indistinguishable isolatesClostridium difficile J Antimicrob Chemother 2000 46 551556

. . ;:–.45. DN Gerding Clindamycin, cephalosporins, fluoroquinolones, and associated diarrhea: this is an antimicrobial resistance problemClostridium difficile Clin Infect Dis 2004 38 646648

, , , . ;:–.46. S Johnson MH Samore KA Farrow et al.Epidemics of diarrhea caused by a clindamycin-resistant strain of in four hospitalsClostridium difficile N Engl J Med 1999 341 16451651

, , . . ; 40:–.49. CHW Klaassen HA van Haren AM Horrevorts Molecular fingerprinting of isolates: pulsed-field gel electrophoresis versus amplified fragment length polymorphismClostridium difficile J Clin Microbiol 2002 101104

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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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