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High frequency of Clostridium difficile infections in Brazil: Results from a multicenter point-prevalence study
Renata N. Pires RN, PhD1,2, Diego R. Falci MD, PhD3,4, Alexandre A. Monteiro BsC1, Cassia F.B. Caurio BsC1,2, Felipe F. Tuon MD, PhD5, Eduardo A. Medeiros MD6, Ivan L. França MD7, Josiane F. John MD8, Teresa C.T. Sukiennik MD2,
Gabriele Z. Saldanha BsC9, Andreza F. Martins PharmD9 and Alessandro C. Pasqualotto MD, MBA, PhD1,2 1Universidade Federal de Ciências da Saúde De Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil, 2Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil, 3Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil, 4Programa de Pós-Graduação em Medicina: Ciências Médicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil, 5Escola de Medicina, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil, 6Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, Brazil, 7Hospital AC Camargo, São Paulo, Brazil, 8Hospital Nossa Senhora da Conceição - GHC, Porto Alegre, Rio Grande do Sul, Brazil and 9Programa de Pós-Graduação em Microbiologia Agrícola e do Ambiente, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
Clostridium difficile is an important pathogen in healthcare facilities. Colonized or infected patients and spore-contaminated environments have been identified as sources for C. difficile infection (CDI). Patients generally develop CDI after exposure to broad-spectrum antibiotics.1,2 The incidence of CDI in Latin America is likely to be underes-
timated due to low clinical suspicion as well as limited availability (and low sensitivity) of diagnostic tools.1,3 Here we report the results of a large survey conducted to determine the frequency of diarrhea and CDI in hospitalized patients in Brazil.
Methods
This point-prevalence study involved adult patients (aged ≥18 years) with diarrhea admitted to 8 university hospitals in Brazil. Hospitals were located in 3 Brazilian state capitals: São Paulo, Curitiba, and Porto Alegre. The study was conducted on 2 distinct dates: March 8, 2017
(summer), and July 12, 2017 (winter). Clinical and demographic data were collected for each patient, including date of onset of current episode of diarrhea, underlying diseases, and antimicrobial use (up to 30 days prior to hospitalization). Patients were excluded if they had been hospitalized in emergency rooms, pediatric wards, and dialysis units. The study was approved by the local ethics committees of the participating hospitals.
Author for correspondence: Alessandro C. Pasqualotto, Email: pasqualotto@
santacasa.org.br Cite this article: Pires RN, et al. (2019). High frequency of Clostridium difficile
infections in Brazil: Results from a multicenter point-prevalence study. Infection Control & Hospital Epidemiology, 40: 484–485,
https://doi.org/10.1017/ice.2019.27
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. Stool sampleswere obtained fromeach enrolled patient. Samples
were refrigerated at 4°C and sent to the reference laboratory within 24 hours (ie, the Molecular Biology Laboratory at Santa Casa de Misericordia de Porto Alegre). Only 1 fecal sample per patient was collected. Culture for C. difficile was performed on fecal samples as fol-
lows. Samples were treated with absolute alcohol (1:1 proportion) at room temperature for 1 hour and subcultured on CM0601 C. difficile agar (Oxoid, Ontario, Canada), enriched with 7% blood horse, D-cycloserine and cefoxitin. The culture was incubated for 48 hours using an anaerobic generator (Genbox, bioMérieux SA, Marcy l’Etaile, France). Suspected colonies were identified at the species level by matrix-assisted laser desorption/ionization mass spectroscopy (MALDI-TOF/MS, Brucker Daltonics, Germany). All fecal samples were investigated for the presence of toxin B
(tcdB), binary toxin (cdtA), and deletion of 117 nucleotides on the tcdC gene using a commercial real-time polymerase chain reaction (PCR) kit (Xpert C. difficile test, Cepheid, Sunnyvale, CA) accord- ing to the manufacturer’s recommendations.4 All patients with diarrhea and positive results for real-time
PCR or culture plus MALDI-TOF were considered confirmed CDI cases. Statistical analyses were performed using JMP version 13.0.0 software (SAS Institute, Cary, NC).
Results
In the 2 days of study, we screened 6,374 patients and 153 pre- sented with diarrhea. The point prevalence of diarrhea was 24.0 per 1,000 patient days (95% confidence interval [CI], 20.5–28.1). Anaerobic culture was positive for 19 patients, 17 of whom had C. difficile confirmed by MALDI-TOF-MS. GeneXpert was
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