Skip to main content

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)...
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.


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.


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.


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.

Corresponding author
University of Pittsburgh Medical Center (UPMC-P), 1215 Kaufmann Building, Pittsburgh, PA
Hide All
1.Gerding DN, Olson MM, Peterson LR, et al.Clostridium difficile-associated diarrhea and colitis in adults: a prospective case-controlled epidemiologic study. Arch Intern Med 1986;146:95100.
2.Bartlett JG. Antibiotic-associated diarrhea. Clin Infect Dis 1992;15:573581.
3.Fekety R, Shah AB. Diagnosis and treatment of Clostridium difficile colitis. JAMA 1993;269:7175.
4.McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204210.
5.Johnson S, Clabots CR, Linn FV, Olson MM, Peterson LR, Gerding DN. Nosocomial Clostridium difficile colonisation and disease. Lancet 1990;336:97100.
6.Brown E, Talbot GH, Axelrod P, Provencher M, Hoegg C. Risk factors for Clostridium difficile toxin-associated diarrhea. Infect Control Hosp Epidemiol 1990;11:283290.
7.Lai K, Melvin ZS, Menard MJ, et al.Clostridium difficile-associated diarrhea: epidemiology, risk factors, and infection control. Infect Control Hosp Epidemiol 1997;18:628632.
8.Pear SM, Williamson TH, Bettin KM, Gerding DN, Galgiani JN. Decrease in nosocomial Clostridium difficile-associated diarrhea by restricting clindamycin use. Ann Intern Med 1994;120:272277.
9.Drapin MS, Worthington MG, Chang TW, Razvi SA. Clostridium difficile colitis mimicking acute peritonitis. Arch Surg 1985;120:13211322.
10.Rubin MS, Bodenstein LE, Kent KC. Severe Clostridium difficile colitis. Dis Colon Rectum 1995;38:350354.
11.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;34:346353.
12.Bartlett JG. Antimicrobial agents implicated in Clostridium difficile toxin-associated diarrhea or colitis. Johns Hopkins Med J 1981;149:69.
13.Gerding DN. Disease associated with Clostridium difficile infection. Ann Intern Med 1989;110:255257.
14.Thibault A, Miller MA, Gaese C. Risk factors for the developmenl of Clostridium difficile-associatei diarrhea during hospital outbreak. Infect Control Hosp Epidemiol 1991;12:345348.
15.Zimmerman RKRisk factors for Clostridium difficile cytotoxin-positive diarrhea after control for horizontal transmission. Infect Control Hosp Epidemiol 1991;12:96100.
16.McFarland LV, Surawicz CM, Stamm WE. Risk factors for Clostridium difficile carriage and C. difficile-associated diarrhea in a cohort of hospitalized patients. J Infect Dis 1990;162:678684.
17.Anand A, Bashey B, Mir T, Glatt AE. Epidemiology, clinical manifestations, and outcome of Clostridium difficile-associated diarrhea. Am J Gastroenterol 1994;89:519523.
18.Cartonili TD, Panigrahi H, Worsley MA, et al.Management and control of a large outbreak of diarrhea due to Clostridium difficile. J Hosp Infect 1994;27:115.
19.Watanakunakorn PW, Watanakunakorn C, Hazy J. Risk factors associated with Clostridium difficile diarrhea in hospitalized adult patients: a case-control study—sucralfate ingestion is not a negative risk factor. Infect Control Hosp Epidemiol 1996;17:232235.
20.Yip C, Loeb M, Salama S, Moss L, Olde J. Quinolone use as a risk factor for nosocomial Clostridium difficile-associateá diarrhea. Infect Control Hosp Epidemiol 2001;22:572575.
21.Tedesco FJ. Ampicillin-associated diarrhea: a prospective study. American Journal of Digestive Diseases 1975;20:295297.
22.Gurwith MJ, Rabin HR, Love K. Diarrhea associated with clindamycin and ampicillin therapy: preliminary results of a cooperative study. J Infect Dis 1977;135(suppl):S104S110.
23.Wiström J, Norrby SR, Myhre EB, et al.Frequency of antibiotic-associated diarrhoea in 2,462 antibiotic-treated hospitalized patients: a prospective study. J Antimicrob Chemother 2001;47:4350.
24.Crabtree T, Pelletier S, Gleason T, Pruett T, Sawyer R. Clinical characteristics and antibiotic utilization in surgical patients with Clostridium difficile-associateá diarrhea. Am Surg 1999;65:507511.
25.Bauwens JE, McFarland LV, Melcher AS. Recurrent Clostridium difficile disease following ciprofloxacin use. Ann Pharmacother 1997;31:1090.
26.Low N, Harries A. Ciprofloxacin and pseudomembranous colitis. Lancet 1990;336:1510.
27.Hillman RJ, Gopal R, Harris RJ. Ciprofloxacin as a cause of Clostridium difficile-associated diarrhea in an HIV antibody positive patient. J Infect 1990;21:205207.
28.Cain DB, O'Conner ME. Pseudomembranous colitis associated with ciprofloxacin. Lancet 1990;336:946.
29.Bates CJ, Wilcox MH, Spencer RC. Ciprofloxacin and Clostridium difficile infection. Lancet 1990;336:1193.
30.Loge RV. Oral fluoroquinolone therapy for Clostridium difficile enterocolitis. JAMA 1989;261:20632064.
31.Gaynes R, Rimland D, Killum E, et al.Outbreak of Clostridium difficile infection in a long-term care facility: association with gatifloxacin use. Clin Infect Dis 2004;38:640645.
32.McCusker ME, Harris AD, Perencevich E, Roghmann M-C. Fluoroquinolone use and Clostridium difficile-associatei diarrhea. Emerg Infect Dis 2003;9:730733.
33.Dallai RM, Harbrecht BG, Boujoukas AJ, et al.Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg 2002;235:363372.
34.Pokrywka M, Croyle K, Pasculle AW, Muto CA. Clostridium difficile colitis resulting in colectomies: case-control study. Presented at the 11th Annual Meeting of the Society for Healthcare Epidemiology of America; April 1-3, 2001; Toronto, Ontario, Canada.
35.Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:5380.
36.Yount RJ, Vries JK, Councill CD. The Medical Archival Retrieval system: an information retrieval system based on distributed parallel processing. Information Processing and Management 1991;27:111.
37.World Health Organization. Anatomical Therapeutic Chemical (ATC) Classification Index With Defined Daily Doses (DDDs). Oslo, Norway: WHO Collaborating Centre for Drug Statistics Methodology; 2000:94100. Available at
38.Mundy LS, Shanholtzer CJ, Willard KE, Gerding DE, Peterson LR. Laboratory detection of Clostridium difficile: a comparison of media and incubation systems. Am J Clin Pathol 1995;103:5256.
39.National Committee for Clinical Laboratory Standards. Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria, ed. 5. Wayne, PA: National Committee for Clinical Laboratory Standards; 2001. Approved standard. Document M11-A5.
40.Clabots CR, Johnson S, Bettin KM, et al.Development of a rapid and efficient restriction endonuclease analysis typing system for Clostridium difficile and correlation with other typing systems. J Clin Microbiol 1993;31:18701875.
41.Rothman KJ, Greenland S. Modern Epidemiology. Philadelphia: Lippincott Williams & Wilkins; 1998:286, 737.
42.Schlesselman JJ. Basic concepts in the assessment of risk. In: Lilienfeld AM, ed. Case-Control Studies: Design, Conduct, Analysis. New York: Oxford University Press; 1982:2768.
43.Clabots CR, Peterson LR, Gerding DN. Characterization of a nosocomial Clostridium difficile outbreak by using plasmid profile typing and clindamycin susceptibility testing. J Infect Dis 1988;158:731736.
44.Wilcox MH, Fawley W, Freeman J, Brayson J. In vitro activity of new generation fluoroquinolones against genotypically distinct and indistinguishable Clostridium difficile isolates. J Antimicrob Chemother 2000;46:551556.
45.Gerding DN. Clindamycin, cephalosporins, fluoroquinolones, and Clostridium difficile associated diarrhea: this is an antimicrobial resistance problem. Clin Infect Dis 2004;38:646648.
46.Johnson S, Samore MH, Farrow KA, et al.Epidemics of diarrhea caused by a clindamycin-resistant strain of Clostridium difficile in four hospitals. N Engl J Med 1999;341:16451651.
47.Kristiansson M, Samore MH, Gerding DN, et al.Molecular differentiation of Clostridium difficile: a comparison of restriction endonuclease analyses, ribotyping, and pulsed field gel electrophoresis. J Clin Microbiol 1994;32:19631969.
48.Rafferty ME, Baltch AL, Smith RP, et al.Comparison of restriction enzyme analysis, arbitrarily primed PCR, and protein profile analysis typing for epidemiologic investigation of an ongoing Clostridium difficile outbreak. J Clin Microbiol 1998;36:29572963.
49.Klaassen CHW, van Haren HA, Horrevorts AM. Molecular fingerprinting of Clostridium difficile isolates: pulsed-field gel electrophoresis versus amplified fragment length polymorphism. J Clin Microbiol 2002; 40:101104.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 11 *
Loading metrics...

Abstract views

Total abstract views: 596 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 23rd January 2018. This data will be updated every 24 hours.