infection control & hospital epidemiology july 2018, vol. 39, no. 7 original article
High Prevalence and Frequent Acquisition of Clostridium difficile Ribotype 002 Among Nursing Home Residents in Hong Kong
Shik Luk, MBBS, MRCP, FRCPath, FHKCPath, FHKAM;1 Alex Yat Man Ho, PhD;1 Eliza Hoi Ying Chan, MSc;2
Iris Hoi Ling Tsang, MStat;2 Tak Keung Ng, MBBS, FRCPath, FHKCPath, FHKAM;1 Wing Kin To, MBChB, FRCPA, FHKCPath, FHKAM;1 Kin Wing Choi, MBChB, MRCP, FRCP, FHKCP, FHKAM;2 Andrew Tin Yau Wong, MBBS, MSc, MPH, FRCP, FFPH, FHKCP, FHKAM2
objective. To determine the incidence and risk factors associated with Clostridium difficile colonization among residents of nursing homes and to identify the ribotypes of circulating C. difficile strains.
design. A prospective cohort study with a follow-up duration of 22 months. setting. Nursing homes.
participants. Of the 375 residents in 8 nursing homes, 300 residents (80.0%) participated in the study. A further prospective study of 4 nursing homes involving 141 residents with a minimum of 90 days of follow-up was also performed.
methods. Baseline and 90-day stool cultures were obtained; additional stool cultures were obtained for residents who had been discharged from hospitals. Polymerase chain reaction (PCR) ribotyping and slpA typing were performed for all C. difficile strains isolated.
results. Toxigenic C. difficile was isolated in 30 residents (10%) at baseline, and 9 residents (7.3%) had acquired toxigenic C. difficile in the nursing homes. The presence of nasogastric tube was an independent risk factor (adjusted odds ratio, 8.59; 95% confidence interval, 1.18–62.53; P=.034) for C. difficile colonization. The Kaplan-Meier estimate of median carriage duration was 13 weeks. The C. difficile ribotypes most commonly identified were 002 (40.8%), 014 (16.9%), 029 (9.9%), and 053 (8.5%).
conclusions. The high incidence of C. difficile colonization and the overrepresentation of C. difficile ribotype 002 confirmed the contribution of nursing home residents to C. difficile transmission across the continuum of care. An infection control program is needed in long-term care.
Infect Control Hosp Epidemiol 2018;39:782–787
Clostridium difficile is an anaerobic, gram-positive, spore- forming bacterium accounting for up to 12% of healthcare- associated infections in the United States.1 The incidence of C. difficile infection (CDI) in Hong Kong markedly increased over the last few years, from 73.9 per 100,000 population in 2009 to 194.9 per 100,000 population in 2013.2 This increase has been partly attributed to switching from toxin enzyme- linked immunoassay (EIA) to the more sensitive nucleic acid amplification test (NAAT) in 2010. Other contributing factors included increased use of broad-spectrum antibiotics and the emergence of C. difficile ribotype 002 with increased sporulation.3 The importance of asymptomatic carriers contributing to
the transmission of CDI in healthcare facilities was highlighted by a genetic analysis suggesting that 29% of C. difficile isolates from hospital-associated infection were highly related to those from carriers.4 In particular, carriers in long-term care
facilities (LTCFs) were implicated as potential sources of transmission due to the high prevalence (>50%) and the high percentages of skin and environmental contamination.5,6 Previous studies have shown that ~30%–40% of healthcare- associated CDIs had onset of infection >4 weeks after admis- sion to an LTCF.7,8 Furthermore, by performing serial rectal swab cultures on admitted patients, Ponnado et al9 demon- strated that the incidence of C. difficile acquisition in a LTCF was 27% over a 6-week follow-up. In fact, local studies have shown that the isolation of epidemic C. difficile ribotype 002 is significantly associated with nursing home residence.2,3 Nevertheless, little is known about the burden and molecular epidemiology of C. difficile colonization in LTCFs in Hong Kong. We evaluated the factors associated with C. difficile colonization and acquisition. The C. difficile isolates identified were further characterized by polymerase chain reaction (PCR) ribotyping to determine their genetic relationship.
Department of Health Hong Kong, China; Infectious Disease Control Training Centre, Hospital Authority, Hong Kong, China. © 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2018/3907-0003. DOI: 10.1017/ice.2018.92
Affiliations: 1. Department of Pathology, Princess Margaret Hospital, Hong Kong, China; 2. Infection Control Branch, Centre For Health Protection, Received January 18, 2018; accepted March 26, 2018; electronically published May 7, 2018
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