Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity

By J. Pépin, Louis Valiquette, M. Alary, Philippe Villemure, A. Pelletier, Karine Forget, K. Pépin, D. Chouinard. Canadian Medical Association Journal, 2004

1,172 citations recorded by the source corpus.

Background: Recent reports suggest that Clostridium difficile colitis may be evolving into a more severe disease. During the second half of 2002 we noted an increase in the number of patients with severe C. difficile-associated diarrhea (CDAD) in our institution. We describe cases of CDAD at our institution over a 13-year period and investigate changes in illness severity. Methods: We undertook a retrospective chart review of all cases of CDAD diagnosed at the Centre hospitalier universitaire de Sherbrooke from Jan. 1, 1991, to Dec. 31, 2003. Because the hospital serves a well-defined population of Quebec, we were also able to calculate population-based incidence during this period. We abstracted data on individual patients from patient charts and from hospital and pharmacy computer databases. We defined cases of CDAD as having a positive C. difficile cytotoxicity assay result, or endoscopic or histopathological evidence of pseudomembranous colitis. A case was considered complicated if one or more of the following was observed: megacolon, perforation, colectomy, shock requiring vasopressor therapy, or death within 30 days after diagnosis. Results: A total of 1721 cases of CDAD were diagnosed during the study period. The incidence increased from 35.6 per 100 000 population in 1991 to 156.3 per 100 000 in 2003; among patients aged 65 years or more, it increased from 102.0 to 866.5 per 100 000. The proportion of cases that were complicated increased from 7.1% (12/169) in 1991–1992 to 18.2% (71/390) in 2003 (p < 0.001), and the proportion of patients who died within 30 days after diagnosis increased from 4.7% (8/169) in 1991– 1992 to 13.8% (54/390) in 2003 (p < 0.001). A high leukocyte count (20.0 х 109/L or greater) and an elevated creatinine level (200 μmol/L or greater) were strongly associated with adverse outcomes: in 2003, 45 (40.9%) of 110 patients with a high leukocyte count or creatinine level, or both, had complicated CDAD and 28 (25.5%) died within 30 days after diagnosis. After adjustment for age and other confounding factors, patients initially given oral vancomycin therapy had a risk of progression to complicated CDAD that was 79% lower than the risk among patients initially treated with metronidazole (adjusted odds ratio 0.2, 95% confidence interval 0.06–0.8, p = 0.02). Interpretation: An epidemic of CDAD with an increased case-fatality rate has had important consequences on the elderly population of our region. Our observational data suggest that the equivalence of vancomycin and metronidazole in the treatment of CDAD needs to be questioned.

Subfields: Epidemiology, Gastroenterology, Infectious Diseases

View Paper: https://www.semanticscholar.org/paper/c04a76dfb1a912bfb94510e71a3d239ea5616d12

How researchers see this paper

The researchers whose trusted networks rank it highest, strongest advocate first. Every researcher gets a different order.

In Epidemiology

In Gastroenterology

J. Bartlett

In Infectious Diseases

Citations in the corpus

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). (2018, positive): “Advanced age, potentially as a surrogate for severity of illness and comorbidities, is one of the most important risk factors for CDI [46, 96, 97], as is duration of hospitalization.”
Mortality attributable to nosocomial Clostridium difficile–associated disease during an epidemic caused by a hypervirulent strain in Quebec (2005, methodology): “5 per 100 000 inhabitants, mostly through nosocomial transmission.(4) The predominant strain in Quebec is a hyperproducer of toxins A and B,(9) inducing severe diarrhea that may facilitate its transmission by incontinent patients.”
Narrative Review: The New Epidemic of Clostridium difficileAssociated Enteric Disease (2006, background): “Furthermore, the disease seemed to be more serious and refractory to therapy, as indicated by increased rates of toxic megacolon, disease requiring colectomy, associated shock, or death (20, 63, 66).”
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings (2007, methodology): “This approach is based on the observation that, for some MDROs, detection of colonization may be delayed or missed completely if culture results obtained in the course of routine clinical care are the primary means of identifying colonized patients.(8,38,107,114,151,153,167,168,183,184,187,189,191-1”
The Changing Epidemiology of Clostridium difficile Infections (2010, background): “A retrospective study of all cases of CDI over a 13-year period in Quebec, Canada, reported an increase in incidence from 35.6 cases per 100,000 population in 1991 to 156.3 cases per 100,000 population in 2003 (152).”
Antimicrobial-associated risk factors for Clostridium difficile infection. (2008, background): “However, the variation between the different ORs is somewhat misleading, and comparisons of ORs from this study cannot be used to distinguish differences in risk between antimicrobials [6, 11, 12, 33, 42, 57].”
Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises (2006, background): “breaks, such as ribotype 027/NAP1 [1–7], it has become”
Development and Validation of a Clostridium difficile Infection Risk Prediction Model (2011, background): “Despite the breadth and depth of knowledge about risk factors available in the medical literature, healthcare facilities still struggle with outbreaks of CDI and increasing rates of disease.(4-7,9,18-20) Most CDI prevention and control strategies, such as the use of contact precautions and environme”
Meta-Analysis of Probiotics for the Prevention of Antibiotic Associated Diarrhea and the Treatment of Clostridium difficile Disease (2006, background): “There is a growing interest in probiotics for the treatment of AAD and CDD due to the wide availability of probiotics as dietary supplements and the concern over recent outbreaks of severe CDD in Canada and the United Kingdom ( 6 , 15).”
Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. (2005, methodology): “using vancomycin as the initial treatment for patients with a leukocyte count of 120,000 cells/mm(3) and/or a creatinine level of 1200 mmol/L—a subgroup of patients with a high shortterm mortality rate [14].”