Infection Control & Hospital Epidemiology
Table 1. Characteristics of Patients with Diarrhea in the Hospital: Comparison of Patients with Clostridium difficile infection (CDI) and Individuals with Diarrhea Due to Other Causes
Others Characteristics
Age, median y (range) Male
Origin of sample (city) Porto Alegre
São Paulo Curitiba
Admission via emergency department
Length of hospital stay before study, median d (range)
Current antimicrobial therapy
Exposure to antimicrobials (current or past 30 d)
Exposure to vancomycin Exposure to carbapenems Exposure to fluoroquinolones
aUnless otherwise specified.
CDI (n = 19), No. (%)a
(n = 134), No. (%)a
58 (24–89) 62 (18–97) 11 (57.9)
71 (53.0)
13 (68.4) 2 (10.5) 4 (21.0) 13 (68.4)
8(0–315)
16 (84.2) 17 (89.7)
6 (31.6) 8 (42.1) 4 (21.1)
93 (68.6) 23 (17.2) 18 (13.4) 93 (69.4)
19 (0–245)
111 (82.8) 112 (83.6)
44 (32.8) 52 (38.8) 9 (6.72)
P Value .974 .688
.316 …
… …
.465 .040
.881 .509
.913 .782 .036
485
collected during a 13-month period, and the frequency of CDI was 31 of 104 (30%).3 In our study, fecal culture plus MALDI-TOF were far more
sensitive than PCR for the laboratorial diagnosis of CDI. The low sensitivity observed with GeneXpert could be attributed to levels of C. difficile that had fallen below the level of detection by PCR, to nontoxigenic strains, or to the inability of the kit to eliminate potential PCR inhibitors from stool samples.7 Clostridium difficile has several other virulence factors associ-
ated with adhesion and intestinal invasion that were not investi- gated in our study. Recent studies have shown variations in the genes of the toxins of PaLoc (pathogenicity locus), which can lead to false negative results in the PCR techniques currently used.7,8 Another limitation of our study was the lack of a comorbidity score or a disease severity measurement, which may have influenced risk factor determination. In conclusion, our findings suggest that Brazil has high rates of
CDI, and criteria for surveillance and epidemiological monitoring are still not well structured. The use of fluoroquinolone as a risk factor for CDI enhances antimicrobial stewardship practices to prevent C. difficile–related disease.
Author ORCIDs. Alessandro C. Pasqualotto, 0000-0002-6782-5395
Acknowledgments.Wewould like to thank all members of the research teams involved in this study, particularly and medical nurse students from Universidade Federal de Ciências da Saúde de Porto Alegre.
positive for 12 of 153 patients. Therefore, CDI was confirmed in 19 subjects, with a point prevalence 3.0 per 1,000 patient days (95% CI, 1.9–4.8). The overall proportion of patients with CDI among screened patients with diarrhea was 11.8% (95% CI, 7.6–17.8). The point prevalence of CDI among diarrhea patients did not
differ between the 2 study periods, with 12 CDI cases (7.8%) in the summer and 7 cases (4.8%) in the winter. The characteristics of CDI patients and patients with diarrhea with other causes are detailed in Table 1. Median time to sample collection was shorter in CDI patients compared to non-CDI patients (8 vs 19 days; P = .041). Exposure to fluoroquinolones was the only variable asso- ciated with CDI risk (relative risk, 3.13; 95% CI, 1.07–9.19). Furthermore, 1 patient (5.2%) presented a hypervirulent C. difficile strain according to real-time PCR.
Discussion
To the best of our knowledge, this is largest point-prevalence study conducted in Latin America to determine the prevalence and risk factors for CDI among hospitalized patients. In 2018, a study in a Brazilian university hospital compared the clinical characteristics among hospitalized adult patients who received antimicrobial treatments and developed CDI. In that study, comorbidity severity indices and the number of antibiotics used during hospitalization were strong independent predictors of nosocomial CDI.5 In a study carried out in the Northeast Region of Brazil in high-risk cancer patients, a high rate of CDI was also found among inpatients with diarrhea: 23 of 48 patients (48%).6 In Latin America, Costa Rica published in 2008 the first study reporting the presence of C. difficile among adults. Samples were
Financial support. This study was sponsored by an unrestricted research grant support from Merck Sharp & Dohme to Dr. Pasqualotto (grant no. MISP 53854).
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References
1. Pires RN, Monteiro AA, Carneiro LC, et al. Clostridium difficile infection in Brazil: a neglected problem? Am J Infect Control 2014;42:459–460.
2. McDonald LC, Gerding DN, Johnson S, et al. 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). Clostridium difficile 2018;66:987–994.
3. Balassiano IT, Yates EA, Domingues RM, Ferreira EO. Clostridium difficile:a problem of concern in developed countries and still a mystery in Latin America. J Med Microbiol 2012;61:169–179.
4. Kok J, Wang Q, Thomas LC, Gilbert GL. Presumptive identification of Clostridium difficile strain 027/NAP1/BI on Cepheid Xpert: interpret with caution. J Clin Microbiol 2011;49:3719–3721.
5. Lopes Cançado GG, Silveira Silva RO, Rupnik M, et al. Clinical epidemiology of Clostridium difficile infection among hospitalized patients with antibiotic- associated diarrhea in a university hospital of Brazil. Anaerobe 2018;54: 65–71.
6. Costa CL, Carvalho CBM, González RH, et al. Molecular epidemiology of Clostridium difficile infection in a Brazilian cancer hospital. Anaerobe 2017;48:232–236.
7. Monot M, Eckert C, Lemire A, et al. Clostridium difficile: new insights into the evolution of the pathogenicity locus. Sci Rep 2015;5:15023.
8. MerriganMM,Venugopal A, Roxas JL, et al. Surface-layer proteinA(SlpA) is a major contributor to host-cell adherence of Clostridium difficile. PLoS One 2013;8:e78404.
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