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CORRESPONDENCE
Year : 2015  |  Volume : 33  |  Issue : 2  |  Page : 326-327
 

Clinical and demographic profile of patients reporting for Clostridium difficile infection in a tertiary care hospital


Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission19-Mar-2014
Date of Acceptance05-Sep-2014
Date of Web Publication10-Apr-2015

Correspondence Address:
C Vaishnavi
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.153570

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How to cite this article:
Vaishnavi C, Singh M, Kapoor P, Kochhar R. Clinical and demographic profile of patients reporting for Clostridium difficile infection in a tertiary care hospital. Indian J Med Microbiol 2015;33:326-7

How to cite this URL:
Vaishnavi C, Singh M, Kapoor P, Kochhar R. Clinical and demographic profile of patients reporting for Clostridium difficile infection in a tertiary care hospital. Indian J Med Microbiol [serial online] 2015 [cited 2019 Dec 12];33:326-7. Available from: http://www.ijmm.org/text.asp?2015/33/2/326/153570


Dear Editor,

Clostridium difficile is the primary cause of hospital-acquired colitis in patients with broad-spectrum antimicrobial use as well as drugs. [1],[2] The hallmark of C. difficile infection (CDI) is the presence of profuse watery, green, foul-smelling or bloody diarrhoea with abdominal cramps and fever. Pathogenicity of C. difficile is due to production of two potent toxins A and B, the detection of which helps in the diagnosis of CDI. We retrospectively reviewed our laboratory records for demographics, clinical presentation, medical history and therapy of 3044 patients with suspected CDI during the study period from October 2009 to June 2012. The Institute Research Ethics Committee approved the investigation. Data were analysed using SPSS 20.0 (IBM Corp. Armonk, New York) and frequency by non-parametric Binomial test and Monte-Carlo test.

The age of the patients ranged from a few days to 87 years and 7.8% of them had inflammatory bowel diseases (IBD). There were 62.5% males and 37.5% females. The predominant clinical symptoms present were diarrhoea (90.2%), abdominal pain (36.5%) and fever (40.6%). The major antibiotic groups in use were nitroimidazole (22.2%), penicillin (19%), quinolones including fluoroquinolones (14.2%), glycopeptides (13%) and carbapenems (8.1%). Apart from the antibiotics, some of the patients also received antifungals, antivirals, proton pump inhibitors, steroids and chemotherapeutics.

C. difficile toxin (CDT) A and/or B detected in the faecal samples using enzyme-linked immunosorbent assay (ELISA) kits (DRG-International Inc, USA) was positive in 17.5% of the patients. Among the 236 (7.8%) patients with IBD, 45 (19%) were positive for CDT. Though CDT positivity was higher (18.1%) in males than in females (16.3%), the difference was not significant (P > 0.05). There was no significant (P > 0.05) association with age group for CDT positivity compared to sample size of each group [Table 1]. CDT positivity was highly associated with gastrointestinal diseases (21.1%), renal diseases (20.8%), surgical conditions (20.7%), hepatic disorders (18.5%) and cancers (17.6%) [Table 2]. Fever was the most significant (41%) clinical symptom present followed by abdominal pain (37.9%) in CDT-positive cases.
Table 1: CDT positivity according to age groups


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Table 2: CDT positivity associated with various clinical conditions


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Patients undergoing antibiotic therapy for unrelated diseases may acquire C. difficile resulting in asymptomatic carriage of the organism or might end up with CDI. Accurate diagnosis of CDI is essential for optimal treatment and prevention. For over two decades,the laboratory diagnosis of CDI has been done by detection of toxins by ELISA, though considered to be suboptimal in terms of sensitivity (60-90%) and specificity (approx. 95%). The positive and negative predictive values of ELISA kits vary depending on the prevalence of patient condition. If the prevalence of CDT in the faecal samples is <10%, the positive predictive value dips to <50% and thus laboratory diagnosis by itself cannot be expected as a reliable diagnosis for clinical management. [3] A false negative result can lead to inappropriate medical management, worsening of CDI, risk of outbreaks and under-reporting; whereas, a false positive result causes lack of appropriate treatment, missing diagnosis of the actual cause of diarrhoea, over-reporting and anxiety to the patient and the family.

Even though patients with antibiotic associated positive CDT in the stool are generally considered to have CDI, the presence of toxin by itself may not necessarily be due to CDI. Earlier workers looking primarily for toxin A or B, missed on cases where A - B + or A + B - strains were the aetiological factors. In the present study, ELISA that detected both toxins A and/or B simultaneously was used thereby minimising the risk of missing either of the toxins.

In a hospital setting, diarrhoea leads to dissemination of the pathogen in the environment. Asymptomatic carriers also produce a reservoir pool of the pathogen. Increasing age and underlying co-morbidities increase the risk of acquiring CDI. Among the underlying co-morbidities identified in the present analysis, gastrointestinal diseases were the commonest, followed by surgical conditions, renal diseases and cancers, and CDT positivity was found in 17-21% of them. Antibiotics like nitroimidazole, penicillin, fluoroquinolones, glycopeptides, carbapenems and drugs like proton pump inhibitors, immunosuppressives and chemotherapeutics were found to be associated with CDT positivity in the present study. Thus, it is important to identify patients who are at high risk for severe CDI early in the course of their infection thereby decreasing the responsibility of the clinicians and improving the patient condition.

Apart from this, only diarrhoeal stools should be tested for C. difficile or its toxins [4] and in case of non-diarrhoeal stools, the patient's records must be reviewed to make certain that the patient has symptoms of CDI. [5] The clinical suspicion for CDI should be based on development of nosocomial diarrhoea with or without accompanying abdominal pain and fever, presence of underlying co-morbidities, exposure to antibiotics and other drugs, and the age of the patient. Readily available clinical data and CDT status can be correlated with severe CDI.


 ~ Acknowledgement Top


The authors are grateful to Dr. Ajay Prakash for statistical analysis of the data.

 
 ~ References Top

1.
Kaur S, Vaishnavi C, Prasad KK, Ray P, Kochhar R. Comparative role of antibiotic and proton pump inhibitor in experimental Clostridium difficile infection in mice. Microbiol Immunol 2007;51:1209-14.  Back to cited text no. 1
    
2.
Kaur S, Vaishnavi C, Ray P, Kochhar R, Prasad KK. Effect of biotherapeutics on cyclosporin-induced Clostridium difficile infection in mice. J Gastroenterol Hepatol 2010;25:832-8.  Back to cited text no. 2
    
3.
Planche T, Aghaizu A, Holliman R, Riley P, Poloniecki J, Breathnach A, et al. Diagnosis of C. difficile infection by toxin detection kits: A systemic review. Lancet Infect Dis 2008;8:777-84.  Back to cited text no. 3
    
4.
Dubberke ER, Reske KA, Olsen MA, McDonald LC, Fraser VJ. Short and long term attributable cost of Clostridium difficile-associated disease in non-surgical patients. Clin Infect Dis 2008;46:497-504.  Back to cited text no. 4
    
5.
Fekety R. Guidelines for the diagnosis and management of Clostridium difficile-associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997;92:739-50.  Back to cited text no. 5
    



 
 
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