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Clostridium difficile in the Intensive Care Unit: Epidemiology, Costs, and Colonization Pressure

Published online by Cambridge University Press:  02 January 2015

Steven J. Lawrence ,
Laura A. Puzniak ,
Brooke N. Shadel ,
Kathleen N. Gillespie ,
Marin H. Kollef  and
Linda M. Mundy
Steven J. Lawrence*
Affiliation:
Divisions of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
Laura A. Puzniak
Affiliation:
Battelle Center of Public Health Research and Evaluation, St. Louis, Missouri
Brooke N. Shadel
Affiliation:
School of Public Health, Saint Louis University, St. Louis, Missouri
Kathleen N. Gillespie
Affiliation:
School of Public Health, Saint Louis University, St. Louis, Missouri
Marin H. Kollef
Affiliation:
Pulmonology/Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
Linda M. Mundy
Affiliation:
School of Public Health, Saint Louis University, St. Louis, Missouri
*
Washington University School of Medicine, Box 8051, 660 South Euclid Avenue, St. Louis, MO 63110 ([email protected])
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Abstract

Objective.

To evaluate the epidemiology, outcomes, and importance of Clostridium difficile colonization pressure (CCP) as a risk factor for C. difficile–associated disease (CDAD) acquisition in intensive care unit (ICU) patients.

Design.

Secondary analysis of data from a 30-month retrospective cohort study.

Setting.

A 19-bed medical ICU in a midwestern tertiary care referral center.

Patients.

Consecutive sample of adult patients with a length of stay of 24 hours or more between July 1, 1997, and December 31, 1999.

Results.

Seventy-six (4%) of 1,872 patients were identified with CDAD; 40 (53%) acquired CDAD in the ICU, for an incidence of 3.2 cases per 1,000 patient-days. Antimicrobial therapy, enteral feeding, mechanical ventilation, vancomycin-resistant enterococci (VRE) colonization or infection, and CCP (5.5 vs 2.0 CDAD case-days of exposure for patients with acquired CDAD vs no CDAD; P = .001) were associated with CDAD acquisition in the univariate analysis. Only VRE colonization or infection (45% of patients with acquired CDAD vs 16% of patients without CDAD; adjusted odds ratio, 2.76 [95% confidence interval, 1.36-5.59]) and a CCP of more than 30 case-days of exposure (20% with acquired CDAD vs 2% with no CDAD; adjusted odds ratio, 3.77 [95% confidence interval, 1.14-12.49]) remained statistically significant in the multivariable analysis. Lengths of stay (6.1 vs 3.0 days; P < .001 by univariate analysis) and ICU costs ($11,353 vs $6,028; P < .001 by univariate analysis) were higher for patients with any CDAD than for patients with no CDAD.

Conclusions.

In this nonoutbreak setting, the CCP was an independent risk factor for acquisition of CDAD in the ICU at the upper range of exposure duration. Having CDAD in the ICU was a marker of excess healthcare use.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 28 , Issue 2 , February 2007 , pp. 123 - 130
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2007

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References

1.Kyne, L, Hamel, MB, Polavaram, R, Kelly, CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis 2002;34:346–353.CrossRefGoogle ScholarPubMed
2.Archibald, LK, Banerjee, SN, Jarvis, WR. Secular trends in hospital-acquired Clostridium difficile disease in the United States, 1987-2001. J Infect Dis 2004;189:1585–1589.Google Scholar
3.Pepin, J, Valiquette, L, Alary, ME, et al. Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ 2004;171:466–472.CrossRefGoogle Scholar
4.Loo, VG, Poirier, L, Miller, MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:2442–2449.Google Scholar
5.McDonald, LC, Killgore, GE, Thompson, A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005;353:2433–2441.Google Scholar
6.Muto, CA, Pokrywka, M, Shutt, K, et al. A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol 2005;26:273–280.CrossRefGoogle Scholar
7.Foulke, GE, Silva, J Jr. Clostridium difficile in the intensive care unit: management problems and prevention issues. Crit Care Med 1989;17:822–826.Google Scholar
8.Walters, BA, Stafford, R, Roberts, RK, Seneviratne, E. Contamination and crossinfection with Clostridium difficile in an intensive care unit. Aust N Z J Med 1982;12:255–258.CrossRefGoogle Scholar
9.Grube, BJ, Heimbach, DM, Marvin, JA. Clostridium difficile diarrhea in critically ill burned patients. Arch Surg 1987;122:655–661.Google Scholar
10.Rotimi, VO, Jamal, WY, Mokaddas, EM, Brazier, JS, Johny, M, Duerden, BI. Prevalent PCR ribotypes of clinical and environmental strains of Clostridium difficile isolated from intensive-therapy unit patients in Kuwait. J Med Microbiol 2003;52:705–709.Google Scholar
11.Pelupessy, I, Bonten, MJ, Diekmann, O. How to assess the relative importance of different colonization routes of pathogens within hospital settings. Proc Natl Acad Sci USA 2002;99:5601–5605.Google Scholar
12.Johnson, S, Gerding, DN. Clostridium difficile-associated diarrhea. Clin Infect Dis 1998;26:1027–1034.Google Scholar
13.Hopkins, MJ, Macfarlane, GT. Changes in predominant bacterial populations in human faeces with age and with Clostridium difficile infection. J Med Microbiol 2002;51:448–454.Google Scholar
14.McFarland, LV, Surawicz, CM, Stamm, WE. Risk factors for Clostridium difficile carriage and C. difficile-associated diarrhea in a cohort of hospitalized patients. J Infect Dis 1990;162:678–684.CrossRefGoogle Scholar
15.Kyne, L, Sougioultzis, S, McFarland, LV, Kelly, CP. Underlying disease severity as a major risk factor for nosocomial Clostridium difficile diarrhea. Infect Control Hosp Epidemiol 2002;23:653–659.Google Scholar
16.Dial, S, Alrasadi, K, Manoukian, C, Huang, A, Menzies, D. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. CMAJ 2004;171:33–38.CrossRefGoogle ScholarPubMed
17.Viscidi, R, Willey, S, Bartlett, JG. Isolation rates and toxigenic potential of Clostridium difficile isolates from various patient populations. Gastroenterology 1981;81:5–9.Google Scholar
18.McFarland, LV, Mulligan, ME, Kwok, RY, Stamm, WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204–210.Google Scholar
19.Chang, VT, Nelson, K. The role of physical proximity in nosocomial diarrhea. Clin Infect Dis 2000;31:717–722.Google Scholar
20.Clabots, CR, Johnson, S, Olson, MM, Peterson, LR, Gerding, DN. Acquisition of Clostridium difficile by hospitalized patients: evidence for colonized new admissions as a source of infection. J Infect Dis 1992;166:561–567.Google Scholar
21.Shim, JK, Johnson, S, Samore, MH, Bliss, DZ, Gerding, DN. Primary symptomless colonisation by Clostridium difficile and decreased risk of subsequent diarrhoea. Lancet 1998;351:633–636.Google Scholar
22.Bonten, MJ, Slaughter, S, Ambergen, AW, et al. The role of “colonization pressure” in the spread of vancomycin-resistant enterococci: an important infection control variable. Arch Intern Med 1998;158:1127–1132.Google Scholar
23.Puzniak, LA, Leet, T, Mayfield, J, Kollef, M, Mundy, LM. To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci. Clin Infect Dis 2002;35:18–25.Google Scholar
24.Merrer, J, Santoli, F, Appered, V, Tran, B, De, JB, Outin, H. “Colonization pressure” and risk of acquisition of methicillin-resistant Staphylococcus aureus in a medical intensive care unit. Infect Control Hosp Epidemiol 2000;21:718–723.Google Scholar
25.Puzniak, LA, Mayfield, J, Leet, T, Kollef, M, Mundy, LM. Acquisition of vancomycin-resistant enterococci during scheduled antimicrobial rotation in an intensive care unit. Clin Infect Dis 2001;33:151–157.Google Scholar
26.Knaus, WA, Draper, EA, Wagner, DP, Zimmerman, JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818–829.Google Scholar
27.Garbutt, JM, Littenberg, B, Evanoff, BA, Sahm, D, Mundy, LM. Enteric carriage of vancomycin-resistant Enterococcus faecium in patients tested for Clostridium difficile. Infect Control Hosp Epidemiol 1999;20:664–670.CrossRefGoogle ScholarPubMed
28.US Department of Labor, Bureau of Labor Statistics. Consumer Price Index for Medical Care. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2003. Available at: http://www.bls.gov/cpi/home.htm. Accessed May 15, 2005.Google Scholar
29.Chen, YY, Chou, YC, Chou, P. Impact of nosocomial infection on cost of illness and length of stay in intensive care units. Infect Control Hosp Epidemiol 2005;26:281–287.Google Scholar
30.Puzniak, LA, Gillespie, KN, Leet, T, Kollef, M, Mundy, LM. A cost-benefit analysis of gown use in controlling vancomycin-resistant Enterococcus transmission: is it worth the price? Infect Control Hosp Epidemiol 2004;25:418–424.Google Scholar
31.Shadel, BN, Puzniak, LA, Gillespie, KN, Lawrence, SJ, Kollef, M, Mundy, LM. Surveillance for vancomycin-resistant Enterococci: type, rates, costs, and implications. Infect Control Hosp Epidemiol 2006;27:1068–1075.Google Scholar
32.Cohen, SH, Tang, YJ, Rahmani, D, Silva, J Jr. Persistence of an endemic (toxigenic) isolate of Clostridium difficile in the environment of a general medicine ward. Clin Infect Dis 2000;30:952–954.Google Scholar
33.Samore, MH, Bettin, KM, DeGirolami, PC, Clabots, CR, Gerding, DN, Karchmer, AW. Wide diversity of Clostridium difficile types at a tertiary referral hospital. J Infect Dis 1994;170:615–621.Google Scholar
34.McFarland, LV. What's lurking under the bed? persistence and predominance of particular Clostridium difficile strains in a hospital and the potential role of environmental contamination. Infect Control Hosp Epidemiol 2002;23:639–640.Google Scholar
35.Kyne, L, Warny, M, Qamar, A, Kelly, CP. Association between antibody response to toxin A and protection against recurrent Clostridium difficile diarrhoea. Lancet 2001;357:189–193.Google Scholar
36.Apisarnthanarak, A, Zack, JE, Mayfield, JL, et al. Effectiveness of environmental and infection control programs to reduce transmission of Clostridium difficile. Clin Infect Dis 2004;39:601–602.Google Scholar
37.Mayfield, JL, Leet, T, Miller, J, Mundy, LM. Environmental control to reduce transmission of Clostridium difficile. Clin Infect Dis 2000;31:995–1000.Google Scholar
38.Gaynes, R, Rimland, D, Killum, E, et al. Outbreak of Clostridium difficile infection in a long-term care facility: association with gatifloxacin use. Clin Infect Dis 2004;38:640–645.Google Scholar
39.McNulty, C, Logan, M, Donald, IP, et al. Successful control of Clostridium difficile infection in an elderly care unit through use of a restrictive antibiotic policy. J Antimicrob Chemother 1997;40:707–711.Google Scholar
40.Baines, SD, Freeman, J, Wilcox, MH. Effects of piperacillin/tazohactam on Clostridium difficile growth and toxin production in a human gut model. J Antimicrob Chemother 2005;55:974–982.Google Scholar
41.Wilcox, MH, Freeman, J, Fawley, W, et al. Long-term surveillance of cefotaxime and piperacillin-tazobactam prescribing and incidence of Clostridium difficile diarrhoea. J Antimicrob Chemother 2004;54:168–172.Google Scholar
42.Perez, J, Springthorpe, VS, Sattar, SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental control. Am J Infect Control 2005;33:320–325.Google Scholar