Indian Journal of Gastroenterology

, Volume 30, Issue 2, pp 89–93 | Cite as

Prevalence and clinical course of Clostridium difficile infection in a tertiary-care hospital: a retrospective analysis

  • Meghraj Ingle
  • Abhijit Deshmukh
  • Devendra Desai
  • Philip Abraham
  • Anand Joshi
  • Camilla Rodrigues
  • Ranjit Mankeshwar
Short Report

Abstract

The spectrum of Clostridium difficile-associated diarrhea (CDAD) is changing. Apart from antibiotic use, other risk factors such as use of proton pump inhibitors (PPI) and immunosuppressive agents, intensive care unit (ICU) stay and inflammatory bowel disease are being recognized. We retrospectively analyzed data on patients whose stool samples were tested for C. difficile toxin (CDT) by enzyme linked immunosorbent assay between June 2006 and May 2008. Demographic and clinical data, and risk factors (antibiotic use, underlying malignancy, chemotherapy, use of PPI, ICU stay) were noted. The details of treatment for CDAD, response, complication and follow up were recorded. Patients whose stool samples were CDT-positive were grouped as study subjects and those with negative stool samples were included in the control group. Of the 99 patients (mean age 46.7 years; 58 men) whose stool samples were tested during this period, 17 (17%) were positive for CDT. As compared with control subjects (n = 82), study subjects were more likely to have fever, prolonged ICU stay, underlying malignancy, and exposure to immunosuppressive and chemotherapeutic agents. On multivariate analysis, exposure to immunosuppressive agents was the only risk factor associated with CDAD. Fifteen patients were treated with metronidazole and two with vancomycin. Two patients did not respond to metronidazole but responded to vancomycin. No patient developed any complication. The prevalence of C. difficile toxin in diarrheal stools sent for C. difficile toxin testing was 17%. Exposure to immunosuppressive agents was a risk factor for the infection. Metronidazole was effective in a majority of patients.

Keywords

Antibiotic-associated diarrhea Immunosuppressive agents Proton pump inhibitors 

References

  1. 1.
    McFarland LV. Diarrhea acquired in the hospital. Gastroenterol Clin North Am. 1993;22:563–77.PubMedGoogle Scholar
  2. 2.
    Bartlett JG, Moon N, Chang TW, Taylor N, Onderdonk AB. Role of Clostridium difficile in antibiotic-associated pseudomembranous colitis. Gastroenterology. 1978;75:778–82.PubMedGoogle Scholar
  3. 3.
    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;34:346–53.PubMedCrossRefGoogle Scholar
  4. 4.
    Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med. 2002;346:334–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Morinville V, McDonald J. Clostridium difficile-associated diarrhea in 200 Canadian children. Can J Gastroenterol. 2005;19:497–501.PubMedGoogle Scholar
  6. 6.
    Bauer MP, Goorhuis A, Koster T, et al. Community-onset Clostridium difficile-associated diarrhoea not associated with antibiotic usage – two case reports with review of the changing epidemiology of Clostridium difficile-associated diarrhoea. Neth J Med. 2008;66:207–11.PubMedGoogle Scholar
  7. 7.
    Chakrabarti S, Lees A, Jones SG, Milligan DW. Clostridium difficile infection in allogeneic stem cell transplant recipients is associated with severe graft-versus-host disease and non-relapse mortality. Bone Marrow Transplant. 2000;26:871–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Bilgrami S, Feingold JM, Dorsky D, et al. Incidence and outcome of Clostridium difficile infection following autologous peripheral blood stem cell transplantation. Bone Marrow Transplant. 1999;23:1039–42.PubMedCrossRefGoogle Scholar
  9. 9.
    Keven K, Basu A, Re L, et al. Clostridium difficile colitis in patients after kidney and pancreas-kidney transplantation. Transpl Infect Dis. 2004;6:10–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Gorschluter M, Glasmacher A, Hahn C, et al. Clostridium difficile infection in patients with neutropenia. Clin Infect Dis. 2001;33:786–91.PubMedCrossRefGoogle Scholar
  11. 11.
    Pulvirenti JJ, Mehra T, Hafiz I, et al. Epidemiology and outcome of Clostridium difficile infection and diarrhea in HIV infected in-patients. Diagn Microbiol Infect Dis. 2002;44:325–30.PubMedCrossRefGoogle Scholar
  12. 12.
    Leonard J, Marshall JK, Moayyedi P. Systematic review of the risk of enteric infection in patients taking acid suppression. Am J Gastroenterol. 2007;102:2047–56. quiz 2057.PubMedCrossRefGoogle Scholar
  13. 13.
    Rodemann JF, Dubberke ER, Reske KA, da Seo H, Stone CD. Incidence of Clostridium difficile infection in inflammatory bowel disease. Clin Gastroenterol Hepatol. 2007;5:339–44.PubMedCrossRefGoogle Scholar
  14. 14.
    Issa M, Vijayapal A, Graham MB, et al. Impact of Clostridium difficile on inflammatory bowel disease. Clin Gastroenterol Hepatol. 2007;5:345–51.PubMedCrossRefGoogle Scholar
  15. 15.
    Kochhar R, Ayyagari A, Goenka MK, Dhali GK, Aggarwal R, Mehta SK. Role of infectious agents in exacerbations of ulcerative colitis in India. A study of Clostridium difficile. J Clin Gastroenterol. 1993;16:26–30.PubMedCrossRefGoogle Scholar
  16. 16.
    Balamurugan R, Balaji V, Ramakrishna BS. Estimation of faecal carriage of Clostridium difficile in patients with ulcerative colitis using real time polymerase chain reaction. Indian J Med Res. 2008;127:472–7.PubMedGoogle Scholar
  17. 17.
    Niyogi SK, Bhattacharya SK, Dutta P, et al. Prevalence of Clostridium difficile in hospitalised patients with acute diarrhoea in Calcutta. J Diarrhoeal Dis Res. 1991;9:16–9.PubMedGoogle Scholar
  18. 18.
    Dhawan B, Chaudhry R, Sharma N. Incidence of Clostridium difficile infection: a prospective study in an Indian hospital. J Hosp Infect. 1999;43:275–80.PubMedCrossRefGoogle Scholar
  19. 19.
    Chaudhry R, Joshy L, Kumar L, Dhawan B. Changing pattern of Clostridium difficile associated diarrhoea in a tertiary care hospital: a 5 year retrospective study. Indian J Med Res. 2008;127:377–82.PubMedGoogle Scholar
  20. 20.
    Katyal R, Vaishnavi C, Singh K. Faecal excretion of brush border membrane enzymes in patients with clostridium difficile diarrhoea. Indian J Med Microbiol. 2002;20:178–82.PubMedGoogle Scholar
  21. 21.
    Gupta U, Yadav RN. Clostridium difficile in hospital patients. Indian J Med Res. 1985;82:398–401.PubMedGoogle Scholar
  22. 22.
    Ayyagari A, Sharma P, Venkateswarlu, Mehta S, Agarwal KC. Prevalence of Clostridium difficile in pseudomembranous and antibiotic-associated colitis in north India. J Diarrhoeal Dis Res. 1986;4:157–60.PubMedGoogle Scholar
  23. 23.
    Al-Eidan FA, McElnay JC, Scott MG, Kearney MP. Clostridium difficile-associated diarrhoea in hospitalised patients. J Clin Pharm Ther. 2000;25:101–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Niyogi SK. Clostridium difficile – associated diarrhoeal diseases: an overview. J Indian Med Assoc. 1995;93:105–7.PubMedGoogle Scholar
  25. 25.
    Vaishnavi C, Thapa BR, Thennarasu K, Singh K. Faecal lactoferrin assay as an adjunct to Clostridium difficile diarrhoea. Indian J Pathol Microbiol. 2002;45:69–73.PubMedGoogle Scholar
  26. 26.
    Gogate A, De A, Nanivadekar R, et al. Diagnostic role of stool culture and toxin detection in antibiotic associated diarrhoea due to Clostridium difficile in children. Indian J Med Res. 2005;122:518–24.PubMedGoogle Scholar
  27. 27.
    Mylonakis E, Ryan ET, Calderwood SB. Clostridium difficile-associated diarrhea: a review. Arch Intern Med. 2001;161:525–33.PubMedCrossRefGoogle Scholar
  28. 28.
    Kelly CP, LaMont JT. Clostridium difficile infection. Annu Rev Med. 1998;49:375–90.PubMedCrossRefGoogle Scholar
  29. 29.
    Bignardi GE. Risk factors for Clostridium difficile infection. J Hosp Infect. 1998;40:1–15.PubMedCrossRefGoogle Scholar
  30. 30.
    Vaishnavi C, Bhasin D, Kochhar R, Singh K. Clostridium difficile toxin and faecal lactoferrin assays in adult patients. Microbes Infect. 2000;2:1827–30.PubMedCrossRefGoogle Scholar
  31. 31.
    Karlstrom O, Fryklund B, Tullus K, Burman LG. A prospective nationwide study of Clostridium difficile-associated diarrhea in Sweden. The Swedish C. difficile Study Group. Clin Infect Dis. 1998;26:141–5.PubMedCrossRefGoogle Scholar
  32. 32.
    Dial S, Delaney JA, Schneider V, Suissa S. Proton pump inhibitor use and risk of community-acquired Clostridium difficile-associated disease defined by prescription for oral vancomycin therapy. CMAJ. 2006;175:745–8.PubMedGoogle Scholar
  33. 33.
    Kumar B, Vaishnavi C, Sandhu K, Kaur I. Clostridium difficile toxin assay in psoriatic patients. Trop Gastroenterol. 2004;25:164–7.PubMedGoogle Scholar
  34. 34.
    Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45:302–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Pepin J, Valiquette L, Alary ME, et al. Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ. 2004;171:466–72.PubMedGoogle Scholar
  36. 36.
    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;31:431–55.PubMedCrossRefGoogle Scholar

Copyright information

© Indian Society of Gastroenterology 2011

Authors and Affiliations

  • Meghraj Ingle
    • 1
  • Abhijit Deshmukh
    • 1
  • Devendra Desai
    • 1
  • Philip Abraham
    • 1
  • Anand Joshi
    • 1
  • Camilla Rodrigues
    • 2
  • Ranjit Mankeshwar
    • 3
  1. 1.Division of GastroenterologyP D Hinduja National Hospital and Medical Research CenterMumbaiIndia
  2. 2.Division of MicrobiologyP D Hinduja National Hospital and Medical Research CenterMumbaiIndia
  3. 3.Division of ResearchP D Hinduja National Hospital and Medical Research CenterMumbaiIndia

Personalised recommendations