A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use

Infect Control Hosp Epidemiol. 2005 Mar;26(3):273-80. doi: 10.1086/502539.

Abstract

Background and objective: Fluoroquinolones have not been frequently implicated as a cause of Clostridium difficile outbreaks. Nosocomial C. difficile infections increased from 2.7 to 6.8 cases per 1000 discharges (P < .001). During the first 2 years of the outbreak, there were 253 nosocomial C. difficile infections; of these, 26 resulted in colectomy and 18 resulted in death. We conducted an investigation of a large C. difficile outbreak in our hospital to identify risk factors and characterize the outbreak.

Methods: A retrospective case-control study of case-patients with C. difficile infection from January 2000 through April 2001 and control-patients matched by date of hospital admission, type of medical service, and length of stay; an analysis of inpatient antibiotic use; and antibiotic susceptibility testing and molecular subtyping of isolates were performed.

Results: On logistic regression analysis, clindamycin (odds ratio [OR], 4.8; 95% confidence interval [CI95], 1.9-12.0), ceftriaxone (OR, 5.4; CI95, 1.8-15.8), and levofloxacin (OR, 2.0; CI95, 1.2-3.3) were independently associated with infection. The etiologic fractions for these three agents were 10.0%, 6.7%, and 30.8%, respectively. Fluoroquinolone use increased before the onset of the outbreak (P < .001); 59% of case-patients and 41% of control-patients had received this antibiotic class. The outbreak was polyclonal, although 52% of isolates belonged to two highly related molecular subtypes.

Conclusions: Exposure to levofloxacin was an independent risk factor for C. difficile-associated diarrhea and appeared to contribute substantially to the outbreak. Restricted use of levofloxacin and the other implicated antibiotics may be required to control the outbreak

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Anti-Bacterial Agents / adverse effects
  • Anti-Bacterial Agents / therapeutic use
  • Case-Control Studies
  • Cause of Death
  • Clindamycin / adverse effects
  • Clindamycin / therapeutic use
  • Clostridium difficile / isolation & purification*
  • Cross Infection / epidemiology
  • Cross Infection / microbiology*
  • Diarrhea / chemically induced
  • Diarrhea / microbiology
  • Disease Outbreaks*
  • Enterocolitis, Pseudomembranous / mortality
  • Enterocolitis, Pseudomembranous / prevention & control*
  • Female
  • Fluoroquinolones / adverse effects
  • Fluoroquinolones / therapeutic use*
  • Hospitals, Teaching
  • Humans
  • Levofloxacin
  • Logistic Models
  • Male
  • Ofloxacin / adverse effects
  • Ofloxacin / therapeutic use
  • Pennsylvania / epidemiology
  • Retrospective Studies
  • Risk Factors

Substances

  • Anti-Bacterial Agents
  • Fluoroquinolones
  • Clindamycin
  • Levofloxacin
  • Ofloxacin