Irish Journal of Medical Science

, Volume 181, Issue 3, pp 315–320 | Cite as

Monitoring Clostridium difficile infection in an acute hospital: prevalence or incidence studies?

  • A. H. Lavan
  • D. P. McCartan
  • M. M. Downes
  • A. D. K. Hill
  • F. Fitzpatrick
Original Article



Surveillance of Clostridium difficile infection (CDI) is an essential component of a CDI preventative programme.


The aim of this study was to evaluate two methods of CDI surveillance.


Prevalence of CDI, antibiotic use and associated co-morbidity was assessed weekly on two wards over 6 weeks. In addition, CDI incidence surveillance was performed on all new CDI cases over a 13-week period. Cases were assessed for CDI risk factors, disease severity, response to treatment and outcome at 6 months.


Clostridium difficile infection prevalence was 3.5% (range 2.9–6.1%) on the medical ward and 1.1% (range 0–3.5%) on the surgical ward. Patients on the medical ward were older and more likely to be colonised with MRSA; however, recent antibiotic use was more prevalent among surgical patients. Sixty-one new CDI cases were audited. Patients were elderly (mean age 71 years) with significant co-morbidity (median age adjusted Charlson co-morbidity score 5). CDI ribotypes included 027 (29 cases) 078 (5) and 106 (4). Eight patients developed severe CDI, seven due to 027. Antibiotic use was common with 56% receiving three or more antibiotics in the preceding 8 weeks. Twenty-four patients had died at 6 months, five due to CDI.


Clostridium difficile infection prevalence gives a broad overview of CDI and points to areas that require more detailed surveillance and requires little time. However, patient-based CDI incidence surveillance provides a more useful analysis of CDI risk factors, disease and outcome for planning preventative programmes and focusing antibiotic stewardship efforts.


Clostridium difficile Surveillance Prevalence study Incidence study Ribotype 027 



This research was funded by the RCSI Alumni Student Research Programme 2008.

Conflict of interest



  1. 1.
    Bignardi GE (1998) Risk factors for Clostridium difficile infection. J Hosp Infect 40(1):1–15PubMedCrossRefGoogle Scholar
  2. 2.
    Carignan A, Allard C, Pepin J, Cossette B, Nault V, Valiquette L (2008) Risk of Clostridium difficile infection after perioperative antibacterial prophylaxis before and during an outbreak of infection due to a hypervirulent strain. Clin Infect Dis 46(12):1838–1843PubMedCrossRefGoogle Scholar
  3. 3.
    Pepin J, Saheb N, Coulombe M-A et al (2005) Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 41(9):1254–1260PubMedCrossRefGoogle Scholar
  4. 4.
    Ricciardi R, Rothenberger DA, Madoff RD, Baxter NN (2007) Increasing prevalence and severity of Clostridium difficile colitis in hospitalized patients in the United States. Arch Surg 142(7):624–631PubMedCrossRefGoogle Scholar
  5. 5.
    Health Protection Agency Annual counts and rates of C. difficile (2007).
  6. 6.
    Loo VG, Poirier L, Miller MA et al (2005) A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 353(23):2442–2449PubMedCrossRefGoogle Scholar
  7. 7.
    Pepin J, Valiquette L, Alary M-E et al (2004) Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ 171(5):466–472PubMedCrossRefGoogle Scholar
  8. 8.
    Warny M, Pepin J, Fang A et al (2005) Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 366(9491):1079–1084PubMedCrossRefGoogle Scholar
  9. 9.
    Kuijper EJ, Barbut F, Brazier JS et al (2008) Update of Clostridium difficile infection due to PCR ribotype 027 in Europe. Euro Surveill 13(31):31Google Scholar
  10. 10.
    Drudy D, Harnedy N, Fanning S, Hannan M, Kyne L (2007) Emergence and control of fluoroquinolone-resistant, toxin A-negative, toxin B-positive Clostridium difficile. Infect Control Hosp Epidemiol 28(8):932–940PubMedCrossRefGoogle Scholar
  11. 11.
    Long S, Fenelon L, Fitzgerald S et al (2007) First isolation and report of clusters of Clostridium difficile PCR 027 cases in Ireland. Euro Surveill 12(4):E070426.3PubMedGoogle Scholar
  12. 12.
    Health Protection Surveillance Committee (2008) Surveillance, diagnosis & management of C. difficile-associated disease in Ireland. (ISBN: 978-0-9551236-3-4)
  13. 13.
    Kuijper EJ, Coignard B, Tull P et al (2006) Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 12(Suppl 6):2–18PubMedCrossRefGoogle Scholar
  14. 14.
    Flanders WD, O’Brien TR (1989) Inappropriate comparisons of incidence and prevalence in epidemiologic research. Am J Public Health 79(9):1301–1303PubMedCrossRefGoogle Scholar
  15. 15.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383PubMedCrossRefGoogle Scholar
  16. 16.
    McNulty C, Logan M, Donald IP et al (1997) Successful control of Clostridium difficile infection in an elderly care unit through use of a restrictive antibiotic policy. J Antimicrob Chemother 40(5):707–711PubMedCrossRefGoogle Scholar
  17. 17.
    Climo MW, Israel DS, Wong ES, Williams D, Coudron P, Markowitz SM (1998) Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost. Ann Intern Med 128:989–995PubMedGoogle Scholar
  18. 18.
    Biller P, Shank B, Lind L et al (2007) Moxifloxacin therapy as a risk factor for Clostridium difficile-associated disease during an outbreak: attempts to control a new epidemic strain. Infect Control Hosp Epidemiol 28(2):198–201PubMedCrossRefGoogle Scholar
  19. 19.
    Sundram F, Guyot A, Carboo I, Green S, Lilaonitkul M, Scourfield A (2009) Clostridium difficile ribotypes 027 and 106: clinical outcomes and risk factors. J Hosp Infect 72(2):111–118PubMedCrossRefGoogle Scholar

Copyright information

© Royal Academy of Medicine in Ireland 2012

Authors and Affiliations

  • A. H. Lavan
    • 1
  • D. P. McCartan
    • 1
  • M. M. Downes
    • 2
  • A. D. K. Hill
    • 1
  • F. Fitzpatrick
    • 2
    • 3
  1. 1.Department of SurgeryBeaumont HospitalDublin 9Ireland
  2. 2.Department of MicrobiologyBeaumont HospitalDublin 9Ireland
  3. 3.Health Protection Surveillance CentreDublinIreland

Personalised recommendations