|Year : 2017 | Volume
| Issue : 2 | Page : 221-225
|Prevalence of Clostridium difficile infection among the patients attending a tertiary care teaching hospital
Lavanya Segar1, Joshy M Easow2, Sreenivasan Srirangaraj1, Mohammad Hanifah3, Noyal M Joseph4, KS Seetha1
1 Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
2 Department of Microbiology, Sri Venkateshwaraa Medical College Hospital and Research Centre, Puducherry, India
3 Department of Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
4 Department of Microbiology, JIPMER, Puducherry, India
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|Date of Web Publication||19-Jun-2017|
| Abstract|| |
Background: Clostridium difficile, a most important nosocomial enteric pathogen, is recognized globally as responsible for antibiotic-associated diarrhea and colitis. It is associated with considerable morbidity and mortality due to widespread use of antibiotics. Aims: The study was done to determine the prevalence of C. difficile infection (CDI) among the patients attending a tertiary care teaching hospital in Puducherry. Settings and Design: We performed a prospective cohort study in Mahatma Gandhi Medical College and Research Institute. Materials and Methods: Around 150 patients were evaluated along with the patient details. C. difficile toxin detection was done as per the standard algorithm using the C. Diff Quik Chek Complete® assay (TECHLAB, Blacksburg, VA, USA). Statistical Analysis Used: Analysis was done using statistics software (SPSS 16.0, SPSS Inc., Chicago, IL, USA). Results: The prevalence of CDI was found to be 4%. More toxin-positive cases were between 50 and 60 years of age, and there was no difference in gender. Intensive Care Unit showed more toxin-positive cases; however, there was no significant association between the occurrence of CDI and the primary diagnosis of the patients. Conclusions: The prevalence of CDI in our hospital was found to be 4%, which was relatively lower compared to other Indian studies. However, awareness of the risk factors may assist in identifying patients at higher risk for CDI, guide implementation of appropriate preventive measures, and modulate potential intervention measure during management.
Keywords: Clostridium difficile, prevalence, toxins
|How to cite this article:|
Segar L, Easow JM, Srirangaraj S, Hanifah M, Joseph NM, Seetha K S. Prevalence of Clostridium difficile infection among the patients attending a tertiary care teaching hospital. Indian J Pathol Microbiol 2017;60:221-5
|How to cite this URL:|
Segar L, Easow JM, Srirangaraj S, Hanifah M, Joseph NM, Seetha K S. Prevalence of Clostridium difficile infection among the patients attending a tertiary care teaching hospital. Indian J Pathol Microbiol [serial online] 2017 [cited 2019 Dec 10];60:221-5. Available from: http://www.ijpmonline.org/text.asp?2017/60/2/221/208383
| Introduction|| |
Clostridium difficile is the most important nosocomial pathogen recognized globally as an enteric pathogen responsible for antibiotic-associated diarrhea (AAD) and colitis. It is a significant cause of morbidity and mortality among hospitalized patients, and the incidence of C. difficile infection (CDI) has dramatically increased due to frequent usage of broad-spectrum antibiotics in these patients. Recent reports estimate the prevalence of CDIs as 20%–30% and in India as 15%–20% in patients taking antibiotics., CDI is associated with a mortality rate of 25% in the elderly people, and at present, the all-cause mortality at 30 days is found to be 15% or greater. Antibiotic therapy alters the colonic microflora with multiplication of C. difficile and production of toxins involved in the pathogenesis of CDI. It has been reported that 3%–5% of healthy adults are asymptomatic carriers reflecting natural immunity  due to the widespread use of antibiotics.
Emergence of BI/NAP1/027, a hypervirulent strain along with indiscriminate use of antimicrobials, and inadequate infection control measures in hospitals are the reasons primarily responsible for the increased incidence of CDI in recent years. The wide variation in the spectrum of clinical manifestations of CDI makes the diagnosis difficult. Further, the wide range of variability in the sensitivity and specificity of the various diagnostic methods and the high cost of these methods add to the difficulty in diagnosis. Despite various researches and development of infection control measures, researchers and clinicians have reported increases in the incidence and severity of CDI in recent years. Although CDI has been well studied in developed countries, there is a paucity of data regarding C. difficile-associated diarrhea in South India, especially in Puducherry where there are no studies to our knowledge. Hence, this study was conducted to study the prevalence of CDI in our population.
| Materials and Methods|| |
A sample size of 150 people was included in this study, which was conducted in the Department of Microbiology and Medicine at Mahatma Gandhi Medical College and Research Institute, a tertiary care teaching hospital in Puducherry, for a period of 20 months. All hospitalized patients with diarrhea, those who presented to medicine outpatient department with diarrhea and had a recent history of exposure to antibiotics and/or antiulcer drugs, and all patients with inflammatory bowel disease were included in this study. Patients with formed stools and those who had received partial or complete treatment for CDI were excluded from this study.
Stool samples were collected from all patients with diarrhea, i.e., watery, loose, or nonformed stools (taking the shape of the container) and having a history of antibiotic therapy or chemotherapy during the last 6 weeks or a previous diagnosis of C. difficile. All the samples were previously unevaluated stool specimens. The samples were collected in a clean, dry disposable container. Only freshly taken specimens were processed, and if the tests could not be performed immediately, they were kept at 4°C–8°C until processing.
Stool culture was done by inoculating the samples into MacConkey agar, Sorbitol MacConkey agar, and Deoxycholate Citrate agar plates (Hi-Media, Mumbai, India) and incubating at 37°C overnight. Any nonlactose-fermenting colony was processed further by standard laboratory methods to rule out other causes of diarrhea. Stool wet mount was done for the presence of any helminthic egg or protozoa. Fecal leukocyte test (FLT) was done by methylene blue staining for the presence of white blood cells (WBC's) being noted. FLT was taken as positive if fecal leukocyte was ≥1 or ≥5 WBC/hpf.
Detection of toxins
The test was done using C. Diff Quik Chek Complete ® (TECHLAB, Blacksburg, VA, USA), a rapid membrane enzyme immunoassay for simultaneous detection of C. difficile glutamate dehydrogenase (GDH) antigen and toxins A and B using specific antibodies in a single reaction well. Using the manufacturer's instructions, the tests were performed, and the results were interpreted.
Percentages were calculated for categorical variables. Means and standard deviations were calculated for numerical variables. Continuous variables were compared using Student's t-test for normally distributed variables. The Chi-square test and Fisher's exact test were used to compare two groups. Univariate analysis was used to study the risk factors for the disease. We confirmed the results of univariate analysis with logistic regression analysis using statistics software (SPSS 16.0, SPSS Inc., Chicago, IL, USA). This was necessary to avoid producing spuriously significant results with multiple comparisons. A stepwise approach was used for entering new terms into the model, with 0.05 as the limit for their acceptance or removal. Results of the logistic regression analyses are reported as estimated odd ratios with their 95% confidence intervals. All P< 0.05 were considered statistically significant and were based on univariate analysis.
| Results|| |
A total of 150 patients suspected to have AAD were included in this study. The mean age of the study patients was 45×93 ± 16×65 (range, 5–82). Of the 150 patients, 89 (59×3%) were male and 61 (40×7%) were female [Figure 1]. The maximum number of suspected cases of CDI were from general surgery (54 cases, 36%), followed by general medicine (33, 22%), Medical Intensive Care Unit (22, 14×7%), Intensive Care Unit (ICU) (16, 10×7%), and others [Table 1]. About 16% (24/150) were positive for GDH, and 4% (6/150) were positive for both C. difficile toxin and GDH. Most of the toxin-positive patients were between 51 and 60 years of age, and there was equal distribution between both the sexes. Two of the six toxin-positive cases were from ICU (33×3%) and one case each in general surgery, general medicine, orthopedics, and urology (16×67%) [Figure 2].
The univariate analysis done for comparison of antibiotics used in patients positive and negative for GDH is shown in [Table 2]. It showed that exposure to doxycycline was associated with 4.7 times increased risk of colonization/infection by C. difficile as suggested by GDH positivity [Table 2]. Logistic regression analysis was performed for confirmation of the findings of univariate analysis [Table 3].
|Table 2: Univariate analysis of antibiotic use in patients positive and negative for glutamate dehydrogenase|
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|Table 3: Logistic regression analysis of antibiotic use in patients positive and negative for glutamate dehydrogenase|
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In this study, a total of 95% of the analyzed group were on multiple antibiotics which included cephalosporins (86%), fluoroquinolones (26%), aminoglycosides (39×3%), penicillin group (12×7%), tetracycline group (5×3%), macrolides (3×3%), metronidazole (92×7%), and vancomycin (6×7%). Even though majority of our patients were given third-generation cephalosporins, exposure to doxycycline was associated with increased risk of colonization/infection by C. difficile. None of the toxin-positive patients were on clindamycin.
| Discussion|| |
The incidence of C. difficile-associated diarrhea in hospitalized patients ranges from 3% to 29%.,,, Most previous studies about CDI in India have shown prevalence rates ranging from 7.1% to 26.6%.,, The prevalence of CDI in our study was found to be 4% [Table 4], which was low, when compared to the observations made in several other studies from India. However, it was consistent with studies done by Ozaki et al., Bashir et al., and the findings of Chaudhry et al. that there was a decrease in CDI prevalence during a 5-year retrospective study though the number of stool specimens tested increased. The reason for the low prevalence may be due to the small population studied and may also be attributed to stringent surveillance and an improved antibiotic policy adopted in our hospital.
Most of the patients studied were between the age group of 50–60, and more number of toxin-positive cases (3 of 6 cases) were from this age group, which was consistent with the study done by Vishwanath et al. Although advanced age ≥60 years was a well-known risk factor associated with CDI due to various factors such as increased use of antibiotics in these patients and presence of several predisposing factors such as severe underlying diseases, comorbid conditions, and senescence of immunity., 2, ,,, CDI has been reported to be more common in women  though various studies from India have reported varying male to female ratios.,, In our study, out of the six toxin-positive cases, three (50%) were male and three (50%) were female. This is in accordance with the study done by Chaudhry et al. Two of the six toxin-positive cases were from ICU (33×3%) and one case each in general surgery, general medicine, orthopedics, and urology (16×67%). This points to the high-risk areas for nosocomial spread of C. difficile isolates and the widespread usage of antibiotics in these wards.,
The patients who developed CDI in the present study were admitted for various clinical disorders. Most predominant primary diagnosis for the patients admitted during the study period was intra-abdominal diseases and infections followed by CNS infections, deep-seated infections, respiratory disease, joint disorders, cardiovascular disease, obstetric conditions, malignancies, urological conditions, neurological disorders, poisoning, and trauma. There was no significant association between the occurrence of CDI and the primary diagnosis of the patients.
CDI was found to be frequently associated with cephalosporins, clindamycin and broad-spectrum penicillins, and quinolones.,,, In this study, a total of 95% of the analyzed group were on multiple antibiotics which included cephalosporins (86%), fluoroquinolones (26%), aminoglycosides (39×3%), penicillin group (12×7%), tetracycline group (5×3%), macrolides (3×3%), metronidazole (92×7%), and vancomycin (6×7%). Azithromycin was found to be of 2.6 times and third-generation cephalosporins with 1.1 times greater risk of CDI as suggested by GDH positivity. Even though majority of our patients were given third-generation cephalosporins, comparison of these antibiotics by univariate analysis showed that exposure to doxycycline was associated with 4.7 times increased risk of colonization/infection by C. difficile as suggested by GDH positivity [Table 2]. Our finding was not consistent with all the studies that have shown tetracyclines to have a protective effect against C. difficile. This may be due to the small sample size and less number of toxin-positive cases and needs further evaluation. However, the findings were consistent with those reported by others in relation to the role of the antibiotics in increasing CDI incidence rates in hospitals. Further, the association between CDI and the implicated antibiotic depended on the prevailing antibiotic usage in the various hospital settings.
Metronidazole is suggested as the first-line drug for the treatment of CDI, and in our study, five of six toxin-positive patients were treated with metronidazole and one case responded to vancomycin. The clinical practice guidelines update by the Society for Healthcare Epidemiology of America and Infectious Diseases Society of America suggest that metronidazole be the drug of choice for the initial episode of mild-to-moderate CDI, and vancomycin be used for initial episode of severe CDI. Therefore, the policy of the use of metronidazole in the treatment of suspected CDI in our hospital is justified.
| Conclusions|| |
Based on the results and the methodology employed, we have concluded that the prevalence of C. difficile toxin positivity was found to be 4%. More toxin-positive cases were between 50 and 60 years of age, and there was no difference in gender. ICU showed more toxin-positive cases, thus pointing to the high-risk areas for nosocomial spread of C. difficile isolates and the widespread usage of antibiotics in this ward. However, there was no significant association between the occurrence of CDI and the primary diagnosis of the patients.
Financial support and sponsorship
This study was financially supported by Miss Gail, TECHLAB, Blacksburg, VA, USA, for providing kits for the research.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vaishnavi C. Clinical spectrum and pathogenesis of Clostridium difficile
associated diseases. Indian J Microbiol 2010;131:487-99.
Mitchell BG, Gardner A. Mortality and Clostridium difficile
infection: A review. Antimicrob Resist Infect Control 2012;1:20.
Kutty PK, Woods CW, Sena AC, Benoit SR, Naggie S, Frederick J, et al.
Risk factors for and estimated incidence of community-associated Clostridium difficile
infection, North Carolina, USA. Emerg Infect Dis 2010;16:197-204.
Bartlett JG. Historical perspectives on studies of Clostridium difficile
and C. difficile
infection. Clin Infect Dis 2008;46 Suppl 1:S4-11.
Ingle M, Deshmukh A, Desai D, Abraham P, Joshi A, Rodrigues C, et al.
Prevalence and clinical course of Clostridium difficile
infection in a tertiary-care hospital: A retrospective analysis. Indian J Gastroenterol 2011;30:89-93.
Tillotson GS, Tillotson J. Clostridium difficile
– A moving target. F1000 Med Rep 2011;3:6.
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.
] [Full text]
Vishwanath S, Singhal A, D'Souza A, Mukhopadhyay C, Varma M, Bairy I. Clostridium difficile
infection at a tertiary care hospital in south India. J Assoc Physicians India 2013;61:804-6.
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.
] [Full text]
Ozaki E, Kato H, Kita H, Karasawa T, Maegawa T, Koino Y, et al. Clostridium difficile
colonization in healthy adults: Transient colonization and correlation with enterococcal colonization. J Med Microbiol 2004;53(Pt 2):167-72.
Bashir G, Zahoor D, Khan MA, Fornda B. Prevalence of C. difficile
in patients with antibiotic associated diarrhea in a tertiary care hospital. Int J Adv Res 2014;2:762-6.
Patel PV, Desai PB. Study of Clostridium difficile
in South Gujarat region of India. Res J Recent Sci 2014;3:34-41.
Garcia C, Samalvides F, Vidal M, Gotuzzo E, Dupont HL. Epidemiology of Clostridium difficile
-associated diarrhea in a Peruvian tertiary care hospital. Am J Trop Med Hyg 2007;77:802-5.
Gogate A, De A, Nanivadekar R, Mathur M, Saraswathi K, Jog A, 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.
Chakraborty A, Kar A, Roy S. Changing trends of Clostridium difficile
associated diarrhoea (CDAD) in a tertiary care hospital in Kolkata, India. Intensive Care Med Exp 2015;3:A118.
Owens RC Jr., Donskey CJ, Gaynes RP, Loo VG, Muto CA. Antimicrobial-associated risk factors for Clostridium difficile
infection. Clin Infect Dis 2008;46 Suppl 1:S19-31.
Gerding DN, Muto CA, Owens RC Jr. Measures to control and prevent Clostridium difficile
infection. Clin Infect Dis 2008;46 Suppl 1:S43-9.
Gould CV, McDonald LC. Bench-to-bedside review: Clostridium difficile
colitis. Crit Care 2008;12:203.
Barbut F, Petit JC. Epidemiology of Clostridium difficile
-associated infections. Clin Microbiol Infect 2001;7:405-10.
Poutanen SM, Simor AE. Clostridium difficile
-associated diarrhea in adults. CMAJ 2004;171:51-8.
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.
] [Full text]
Vaishnavi C. Established and potential risk factors for Clostridum difficile
infection. Indian J Med Microbiol 2009;27:289-300.
] [Full text]
Hookman P, Barkin JS. Clostridium difficile
associated infection, diarrhea and colitis. World J Gastroenterol 2009;15:1554-80.
Viswanathan VK, Mallozzi MJ, Vedantam G. Clostridium difficile
infection: An overview of the disease and its pathogenesis, epidemiology and interventions. Gut Microbes 2010;1:234-42.
Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, 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.
Joshy M Easow
Department of Microbiology, Sri Venkateshwaraa Medical College Hospital and Research Centre, Puducherry - 605 102
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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