The evaluation of Clostridium difficile infection (CDI) in a community hospital

Introduction: Clostridium difficile is a serious reemerging pathogen in Europe and North America. C. difficile infection (CDI) has been of concern over the last decade in view of its significant morbidity and mortality, as well as the high health care costs involved with each case. Although multiple risk factors are known to be associated with CDI, a number of patients develop severe infection even in the absence of known risk factors. CDI is diagnosed by the detection of the toxin A/B in stools by enzyme immunoassay (EIA) or by polymerase chain reaction (PCR). There is conflicting literature regarding whether any particular group of antibiotics is associated with higher risk for CDI. There is also a tendency to perform repeated stool tests for toxin A/B if the first test is negative. We evaluated 100 consecutive hospitalized patients who tested positive for C. difficile over a one-year period.

Methods: We performed a retrospective analysis of 100 consecutive patients with CDI admitted to our hospital between July 2008 and June 2009. Patient records were reviewed for risk factors, treatment, and clinical outcomes. We also evaluated the number of stool tests performed for the detection of C. difficile and fecal leukocyte testing in each patient.

Results: The majority of the patients were more than 60 years of age (87%). Forty-four percent of patients presented from a nursing facility. More than 50% were on Proton Pump Inhibitors (PPIs) at the time of admission. Co-morbidities in our patients included malignancy in 28%, diabetes mellitus in 25%, and chronic renal disease in 23%. Most of the patients had multiple co-morbidities. Patients who had taken antibiotics in the previous six months constituted 74% of the total study population. A beta-lactam alone or in combination with other antibiotics was prescribed in 48%, quinolones in 13% and clindamycin in 4% of patients. Stool samples were tested only once in 53% of patients and twice or more in 43%. Metronidazole was the initial therapy in 86% of patients. Intensive care unit stay was required in 33% of patients. Seventeen percent died during their hospitalization.

Conclusions: Elderly patients are especially vulnerable to CDI when exposed to antibiotics, and higher mortality and morbidity is observed in this age group. PPI use was common in our patients. Metronidazole was used as the first line agent in the majority of patients. We also determined a tendency to test for the C. difficile toxin in more than one stool sample. All of these practices need to be modified based on the current guidelines.