
Clostridium difficile. David B. Blossom, MD MS Division of Healthcare Quality Promotion Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention. Objectives. Review of Clostridium difficile Discuss the transmission and virulence of C. difficile
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David B. Blossom, MD MS
Division of Healthcare Quality Promotion
Coordinating Center for Infectious Diseases
Centers for Disease Control and Prevention
associated pseudomembranous colitis3
antimicrobial-associated diarrhea (20-30% of cases)
1. Brazier JS, al Saif. J Med Microbiol 1996; 45: 133-7
2. Hall I; O'Toole E. Am J Dis Child 1935; 49: 390
3. Larson HE et al. Lancet 1978; 8073: 1063–1066.
Diagram: Sunenshine et al Clev Clin J Med 2006 73(2) 187-197
Diagram: Sunenshine, et al. Clev Clin J Med 2006 73: 187-197
1.Geric B, et al. J Med Micro 2004;53:887-94
- Has become the hallmark of
CDAD1
- Bloody diarrhea
- Raised whitish-yellow plaques
- Unexplained leukocytosis
(>10,000/cubic mm )
Healthy colon
Pseudo-membranous colitis
1.Bartlett JG, et al. Gastroenterology 1978; 75:778-82
- a dilated colon (megacolon)
- Diameter : ≥ 5.5 cm
- Fever, abdominal pain, abdominal
distension
- Radiograph: apparent edema of
bowel wall
- Perforation of colon
- Sepsis, Shock
- Death
Diagram: http://www.nlm.nih.gov/medlineplus/ency/imagepages/17189.htm
Exposed to C. difficile
Antibiotic therapy
Disturbed colonic microflora
Toxin A & Toxin B
Diarrhea & colitis
1.Brown E et al. Infect Control Hosp Epi 1990;11: 283-90
2. Johnson S, et al Lancet 1990;336:97-100
3. M. Delmee Clin Microbiol Infect 2001; 7: 411-416
1.Karlstrom et al. Clin Infect Dis 1998;26:141-5
2.Pepin et al. CMAJ 2004;171:466-72
1.WistromJ et al. J Antimicrob Chemother 2001;47:43-50
2. Pepin J. Clin Infect Dis. 2005 Nov 1;41(9):1254-60
1 Loo VG, et al. NEJM 2005; 353:2442-9
2 Muto CA et al. Infect Control Hosp Epidemiol 1005; 26:273-80
1.McFarland et al. N Engl J Med 1989;320:204-10
2. Clabots et al. JID 1992;166:561-67
= daily exposure to CDAD patients
Length of stay at risk
Dubberke et al. Arch Int Med 2007; 167: 1092-7
- Requiring 2-3 days for growth
- Unable to distinguish between the presence of toxin positive strains or toxin negative strains
- Cytotoxin B
- May detect Toxin A only or Toxin A and B
C difficile colonies on agar plate: http://en.wikipedia.org/wiki/Clostridium_difficile
- Within 2 to 3 days after discontinuation
- But most patients require specific treatment
1. Zar FA, et al. CID 2007; 45: 302-7 2. Johnson S, et al. CID 2007; 44: 846-8
- Average of $3,600 excess costs per case
- Average of 3.6 extra hospital days
* Kyne L, et al. Clin Infect Dis. 2002;34:346-353
McDonald et al. 14th Annual Scientific Meeting of the
Society for Healthcare Epidemiology of America, Philadelphia, PA. 2004
National Estimates of US Short-Stay Hospital Discharges with C. difficile as First-Listed or Any Diagnosis
McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15
Rates of US Short-Stay Hospital Discharges with C. difficile Listed as Any Diagnosis by Age
McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15
United Kingdom, 1994-51
Pittsburgh, 20002
Quebec, Canada, 20043
1. MacGowan AP, et al. J Antimicrob Chemother 1997;39:537-41
2. Dallal RM, et al. Ann Surg. 2002;235:363-372.
Loo VG, et al. NEJM 2005;353:2442-2449
3. Pepin J et al. CMAJ. 2005;173(23):1037-42.
- Increase in exposure to healthcare facilities
- Increase exposure to antimicrobials
- Important prevention strategy
- HCWs can transmit C. difficile
No relationship between alcohol-based hand rubs and increasing rates of CDAD
Boyce et al. Infect Control Hosp Epidemiol 2006; 27:479-483
- Increases risk for C. difficile3
1. Jones RN, Mandell LA. Diagn Microbiol Infect Dis. 2002;44:69–76
2. MacDougall C et al Emerg Infect Dis . 2005 ; 11(3):380-4
3. Bignardi GE. J Hosp Infect 1998; 40:1–15.
4. Kallen et al.Arch Int Med. 2005
1 Johnson S, et al. N Engl J Med 1999;341:1645-51
2 Warny M, et al. Lancet 2005; 366: 1079-84
1
2
1
1
1
Acute Care Hospitals with CDAD Outbreaks* Between 2001-2004*Detected by increases in the number of positive routine clinical laboratory tests for C. difficile.
McDonald LC, et al. N Engl J Med. 2005;353:2433-2441.
Pennsylvania
Pennsylvania
Maine, Hospital B
Maine, Hospital B
Illinois
Illinois
Georgia
Maine, Hospital A
New Jersey
New Jersey
Oregon
Historic, 1988-1991
Historic, 1993
Historic, 1993-2000
Oregon
Historic, 1990-1991
Historic, 1984-1991
Common (Epidemic) Strain by PFGE1 Includes 5 historic “BI” isolates
2 32 (89%) were toxinotype 0 or wild type
In vitro production of toxins A and B by C. difficile isolates. Median concentration and IQRs are shown. C. difficile strains included 25 toxinotype 0 and 15 NAP1/027 strains (toxinotype III) from various locations.
Warny M, et al. Lancet. 2005;366:1079-1084.
In vitro production of toxins A and B by C. difficile isolates. Median concentration and IQRs are shown. C. difficile strains included 25 toxinotype 0 and 15 NAP1/027 strains (toxinotype III) from various locations.
Warny M, et al. Lancet. 2005;366:1079-1084.
DC
HI
PR
AK
BBC News. http://news.bbc.co.uk/2/hi/health/4186834.stm
1.Kuiper EJ et al. Emerg Infect Dis 2006;12(5):827-830.
2. Goorhuis A et al. CID 2007; 45: 695-703
Eurosurveillance Weekly Release. http://www.eurosurveillance.org/index.asp
CDC. MMWR. 2005;54:1201-1205.
CDC. MMWR. 2005;54:1201-1205.
CDC. MMWR. 2005;54:1201-1205.
67 total
cases*
99 total
cases
93 total
cases
73 total
cases
Gaynes, R et al. ICAAC 2006, San Francisco
Gaynes, R et al. ICAAC 2006, San Francisco
1Songer JG, et al. Anaerobe 2006; 12: 1-4
2Rodriguez-Palacios A, et al. EID 2007; 13: 485-7
3Arroyo LG, et al. J Med Microbiol 2005; 54: 163-6
Dramatic, Severe
Disease In Healthy,
Young Persons
Antibiotic-associated
Inpatient Disease
?
Diarrhea in older
ambulatory
patients +/-
chronic conditions
Antibiotics? NSAIDS? PPIs?
H2 blockers?
Source: Human-to-Human and ?
or
2. Pseudomembranous colitis on endoscopy or surgery
or
3. Pseudomembranous colitis seen on histopathology
Hospitalization
Admission
Discharge
3 months after Discharge
48 h
4 weeks
8 weeks
CA
HO
CO-HCFA
Indeterminate
CA
McDonald LC, et al. ICHE 2007; 28: 140-45
McDonald LC, et al. ICHE 2007; 28: 140-45
*See C. difficile fact sheets: http://www.cdc.gov/ncidod/dhqp/
1 Weber DJ et al. JAMA 2003;289:1274
Impact of Hydrogen Peroxide Vapor Room Bio-Decontamination on Environmental Contamination and Nosocomial Transmission by Clostridium difficile
John M. Boyce1, MD, Nancy L. Havill1, MT,
Jonathan A. Otter2, BSc, L. Clifford McDonald3, MD
Nicholas M.T. Adams2, BSc, Angela Thompson3, MSc,
Lois Wiggs3, Judith Noble-Wang3, PhD
Hospital of Saint Raphael1, New Haven, CT
Bioquell PLC2, Andover, England
Centers for Disease Control & Prevention3, Atlanta, GA
- CDAD in patients without traditional risk factors
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Recommendations for CliniciansCampaign to Prevent Antimicrobial Resistance in Healthcare Settings
Recommendations for CliniciansUse Antimicrobials Wisely
http//:www.cdc.gov/ncidod/dhqp/index.html
The information presented here represents the opinion of the presenter and does not necessarily represent the opinion of the US Public Health Service, the Centers for Disease Control and Prevention or the Department of Health and Human Services
dblossom@cdc.gov
http//:www.cdc.gov/ncidod/dhqp/index.html