Hostname: page-component-76fb5796d-45l2p Total loading time: 0 Render date: 2024-04-26T07:01:11.070Z Has data issue: false hasContentIssue false
  • English
  • Français

Predicting Clostridium difficile Toxin in Hospitalized Patients With Antibiotic-Associated Diarrhea

Published online by Cambridge University Press:  02 January 2015

Nir Peled ,
Silvio Pitlik ,
Zmira Samra ,
Arkadi Kazakov ,
Yoram Bloch  and
Jihad Bishara
Nir Peled
Affiliation:
Institute of Pulmonology, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Silvio Pitlik
Affiliation:
Department of Internal Medicine C, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Zmira Samra
Affiliation:
Laboratory of Clinical Microbiology, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Arkadi Kazakov
Affiliation:
Department of Internal Medicine C, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Yoram Bloch
Affiliation:
Recanati Center for Research and Medicine, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Jihad Bishara*
Affiliation:
Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
*
Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa 49100, Israel (bishara@netvision.net.il)
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective.

Clostridium difficile infection is implicated in 20%-30% of cases of antibiotic-associated diarrhea. Studying hospitalized patients who received antibiotic therapy and developed diarrhea, our objective was to compare the clinical characteristics of patients who developed C. difficile–associated diarrhea (CDAD) with those of patients with a negative result of a stool assay for C. difficile toxin.

Methods.

A prospective study was done with a cohort of 217 hospitalized patients who had received antibiotics and developed diarrhea. Patients with CDAD were defined as patients who had diarrhea and a positive result for C. difficile toxin A/B by an enzyme immunoassay of stool. The variables that yielded a significant difference on univariate analysis between patients with a positive assay result and patients with a negative assay result were entered into a logistic regression model for prediction of C. difficile toxin.

Setting.

A 900-bed tertiary care medical center.

Results.

Of 217 patients, 52 (24%) had a positive result of assay for C. difficile toxin A/B in their stool. The logistic regression model included impaired functional capacity, watery diarrhea, use of a proton pump inhibitor, use of a histamine receptor blocker, leukocytosis, and hypoalbuminemia. The area under the receiver operating characteristic curve for the model as a predictor of a positive result for the stool toxin assay was 0.896 (95% confidence interval, 0.661-1.000; P<.001), with 95% specificity and 68% sensitivity.

Conclusions.

Our results may help clinicians to predict the risk of CDAD in hospitalized patients with antibiotic-associated diarrhea, to guide careful, specific empirical therapy, and to direct early attention to infection control issues.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 28 , Issue 4 , April 2007 , pp. 377 - 381
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2007

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.)

References

1.Drummond, LJ, McCoubrey, J, Smith, DG, Starr, JM, Poxton, IR. Changes in sensitivity patterns to selected antibiotics in Clostridium difficile in geriatric in-patients over an 18-month period. J Med Microbiol 2003;52:259–263.Google Scholar
2.Schroeder, MS. Clostridium difficile–associated diarrhea. Am Fam Physician 2005;71:921–928.Google Scholar
3.Kelly, CP, Pothoulakis, C, LaMont, JT. Clostridium difficile colitis. N Engl J Med 1994;330:257–262.Google Scholar
4.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
5.Loo, GV, Poirier, L, Miller, MA, et al.A predominantly clonal multi-institutional outbreak of Clostridium difficile–associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:2442–2449.Google Scholar
6.Kyne, I, 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
7.Samra, Z, Talmor, S, Bahar, J. High prevalence of toxin A-negative toxin B-positive Clostridium difficile in hospitalised patients with gastrointestinal diseases. Diagn Microbiol Infect Dis 2002;43:189–192.Google Scholar
8.Hanley, JA. Receiver operating characteristic (ROC) methodology: the state of the art. Crit Rev Diagn Imaging 1989;29:307–335.Google Scholar
9.Hanley, JA, McNeil, BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982;143:29–36.Google Scholar
10.Cooper, GS, Lederman, MM, Salata, RA. A prediction model to identify Clostridium difficile toxin in hospitalized patients with diarrhea. Am J Gastroenterol 1996;91:80–84.Google Scholar
11.McFarland, LV, Surawicz, CM, Stamm, WE. Risk factors for Clostridium difficile carriage and Clostridium difficile associated diarrhea in a cohort of hospitalized patients. J Infect Dis 1990;162:678–684.Google Scholar
12.Kyne, L, Sogioultzis, S, McFarland, LV, Kelly, CP. Underlying disease severity as a major risk factor for nosocomial Clostridium difficile diarrhea. Infect Control Hosp Epidemiol 2002;23:653–659.Google Scholar
13.Brown, E, Talbot, GH, Axelrod, P, Provencher, M, Hoegg, C. Risk factors for Clostridium difficile toxin associated diarrhea. Infect Control Hosp Epidemiol 1990;11:283–290.Google Scholar
14.Modena, S, Bearelly, D, Swartz, K, Friedenberg, F. Clostridium difficile among hospitalized patients receiving antibiotics: a case-control study. Infect Control Hosp Epidemiol 2005;26:685–690.Google Scholar
15.Wanathia, A, Goldsmith, EA, Musher, DM. Conditions associated with leukocytosis in a tertiary care hospital, with particular attention to the role of infection caused by Clostridium difficile. Clin Infect Dis 2002;34:1585–1592.Google Scholar
16.Bartlett, JG. Leukocytosis and Clostridium difficile-associated diarrhea. Am J Gastroenterol 2000;95:3023–3024.Google Scholar
17.Bulusu, M, Narayan, S, Shetler, K, Triadafilopoulos, G. Leukocytosis as a harbinger and surrogate marker of Clostridium difficile infection in hospitalized patients with diarrhea. Am J Gastroenterol 2000;95:3137–3141.CrossRefGoogle ScholarPubMed
18.Dial, S, Alrasadi, K, Manoukian, C, Huang, A, Menzies, D. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. Can Med Assoc J 2004;171:33–38.Google Scholar
19.Cunningham, R, Dale, B, Undy, B, Gaunt, N. Proton pump inhibitors as a risk factor for Clostridium difficile associated diarrhea. J Hosp Infect 2003;54:243–245.Google Scholar
20.Williams, C. Occurance and significance of gastric colonization during acid inhibitory therapy. Best Pract Res Clin Gastroenterol 2001;15:511–521.Google Scholar
21.Katz, DA, Lynch, ME, Littenberg, B. Clinical prediction rules to optimize cytotoxin testing for Clostridium difficile in hospitalized patients with diarrhea. Am J Med 1996;100:487–495.CrossRefGoogle ScholarPubMed
22.Katz, DA, Bates, DW, Rittenberg, E, et al.Predicting Clostridium difficile stool cytotoxin results in hospitalized patients with diarrhea. J Gen Intern Med 1997;12:57–62.Google Scholar
23.Hornbuckle, K, Chack, A, Lazarus, HM, et al.Determination and validation of a predictive model for Clostridium difficile diarrhea in hospitalized oncology patients. Ann Oncol 1998;9:307–311.Google Scholar
24.Talbot, RW, Walker, RC, Beart, RW JrChanging epidemiology diagnosis and treatment of Clostridium difficile toxin associated colitis. Br J Surg 1986;73:457–460.Google Scholar
25.Gebhard, RL, Gerding, DN, Olson, MM, et al.Clinical and endoscopic findings in patients early in the course of Clostridium difficile associated pseudomembranous colitis. Am J Med 1985;78:45–48.Google Scholar