c.difficilecolonization and ribotypes in hong kong 785
table 3. Univariate Analysis and Multivariable Logistic-Regression of the Risk Factors Associated With C. difficile Colonization Risk Factor
Colonized (N=18)
Age, mean y ±SD (median) Sex, male
Duration of residence, mean mo ±SD (median)
Hepatic disease
History of hospitalization within 12 weeks Penicillin group antibiotics within 12 weeksa Proton pump inhibitor within 12 weeks Bed-bound functional status
Barthel index, mean ±SD (median) Presence of devicesb Urinary catheter Nasogastric tube
6 (33.3)
Not colonized (N=135)
Unadjusted OR (95% CI)
P Value
82.9±7.2 (83.5) 82.1±10.4 (83) 1.01 (0.96–1.06) .814 53 (39.3) 0.77 (0.27–2.19) .628
29.2±25.5 (25.7) 33.9±39.6 (21.5) 0.10 (0.98–1.01) .984 2 (11.1)
11 (61.1) 7 (38.9) 7 (38.9) 4 (22.2)
5 (27.8) 1 (5.6)
4 (22.2)
1 (0.7) 16.75 (1.44–195.23) .037 13.23 (0.90–194.75) .06 34 (25.2) 4.67 (1.68–13.00) .002 2.10 (0.51–8.63) .306 18 (13.3) 4.14 (1.42–12.06) .013 2.33 (0.56–9.69) .246 23 (17.0) 3.10 (1.09–8.84) .051
7 (5.3) 5.14 (1.34–19.78) .028 0.84 (0.10–6.93) .872
38.3±42.8 (19) 47±35.8 (45.5) 0.99 (0.98–1.01) .243 14 (10.4) 3.32 (1.03–10.72) .051 7 (5.2) 1.08 (0.13–9.29) 1
4 (3.0) 9.36 (2.11–41.58) .007 8.59 (1.18–62.53) .034
significance. aPenicillin group antibiotics included penicillins, aminopenicillins, carboxypenicillins, ureidopenicillins and β-lactam/β-lactamase inhibitor
NOTE. C. difficile, Clostridium difficile; SD, standard deviation. Data are no. (%), unless otherwise indicated. Bold P values indicate statistical
combinations (ie, amoxicillin-clavulanate, ticarcillin-clavulanate, ampicillin-sulbactam, and piperacillin-tazobactam). bDevices included urinary catheters, nasogastric tubes, percutaneous endoscopic gastrostomy tubes, tracheostomy tubes, and Tenckoff catheters for peritoneal dialysis.
that reported in Germany (3.8%), the United States (4%), and Ireland (7%) in the absence of a recognized outbreak.15–17 The lack of handwashing facilities was a possible explanation. In 4 nursing homes, >20 residents shared a single handwashing facility. This condition may have prevented healthcare workers from per- forming hand hygiene after diaper changes and before naso- gastric tube feedings. Healthcare workers in the nursing home with the highest prevalence of C. difficile colonization did not undergo regular infection control training. In this context, the gaps in the current infrastructure emphasize the need to improve infection control management in nursing homes. For the residents (N=36) who had toxigenic C. difficile
figure 1. Kaplan-Meier estimate of the duration of Clostridium difficile carriage for the 35 nursing home residents with a follow-up duration ≥90 days with positive cultures at baseline sampling or sampling upon nursing home residence. The dotted lines show the 95% confidence interval of the curve.
The C. difficile strains first isolated from 71 residents were subjected to PCR ribotyping. The most common ribotypes identified were 002 (N=29, 40.8%), 014 (N=12, 16.9%), 029 (N=7, 9.9%), and 053 (N=6, 8.5%).
discussion
The prevalence of toxigenic C. difficile carriage among nursing home residents ranged from 3.8% to 51.5%. High rates of carriage were invariably associated with CDI outbreaks.14 TheprevalenceinHongKongwas 10%,which washigherthan
isolated in this study, 8 (22%) had been admitted to hospitals with the presentation of acute diarrhea within 1 year of posi- tive culture. This finding is in agreement with a previous study.5 However, stool specimens of only 2 patients were sent for toxigenic C. difficile testing. Clinical suspicion for CDI should not be limited to patients who present with hospital- onset diarrhea; in fact, nursing-home–onset CDI contributed a significant disease burden.2 This finding is further supported by the predominance of epidemic C. difficile ribotype 002 strains among colonized nursing home residents (40.8%) in this cohort. The frequent movement of patients between nursing homes
and hospitals presented another challenge for the control of C. difficile transmission. In Hong Kong, up to 20% of admitted patients in the medical units are nursing home residents.18 Together with residents with undiagnosed CDI, they serve as reservoirs for continuous C. difficile transmission in healthcare settings. The process is dynamic and is amplified in these rela- tively resource-deprived nursing homes. In this study, recent
Adjusted OR (95% CI)
P Value
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140 |
Page 141 |
Page 142 |
Page 143 |
Page 144
