Clinico-microbiological analysis of toxigenic clostridium difficile from hospitalised patients in a tertiary care hospital, Mangalore, Karnataka, India

Purpose: Prevalence of Clostridium difficile, an anaerobic, Gram-positive, spore-forming bacillus, is very much underestimated in India. The present study was intended to assess the burden of toxigenic C. difficile in hospitalised patients with clinically significant diarrhoea and analysis of their clinical picture. Materials and Methods: This cross-sectional study was conducted in a tertiary care teaching hospital, South India, from January 2012 to December 2014. Stool samples were collected consecutively from 563 inpatients from various wards. The prevalence of toxigenic C. difficile was determined by toxigenic culture and a two-step algorithm. The clinical spectrum of these patients was also analysed. Associated pathogens were identified using standard procedures. Statistical analysis was done by frequency, percentage, Chi-square test and z-test. Results: Out of the 563 stool samples analysed, the prevalence of toxigenic C. difficile was 12.79% and that of non-toxigenic C. difficile was 10.83%. The prevalence of toxigenic C. difficile among oncology patients was highly significant (HS). Antibiotic treatment, prolonged hospital stay and underlying diseases/conditions were the risk factors which were HS, and fever was the significant clinical feature among the patients. Escherichia coli was the predominant associated pathogen isolated (18.47%). Conclusion: The presence of toxigenic C. difficile in our locality is a matter of concern. Constant supervision, appropriate treatment and preventive measures are crucial in controlling C. difficile infection.

To Study the Prevalence of Clostridium Difficile in Cases of Antibiotic Associated Diarrhoea in a Tertiary Care Hospital in North India

Clostridium difficile is a gram positive spore forming bacilli which can be normally present in human colon in some individuals. It can cause clostridium difficile infection which can lead to Clostridium difficile associated disease(CDAD) which is manifested by diarrhoea and in fulminant cases by pseudomembranous colitis and can lead to death. Disruption of normal intestinal flora by antimicrobials and lowering of immunity leads to its overgrowth and disease manifestations. Aims And Objectives: 1. To find the prevalence of clostridium difficile in stool samples of patients presenting with antibiotic associated diarrhoea. 2. To find the risk factors associated with the disease. Methods: The study was conducted from January 2017 to June 2018 on 131 stools samples of patients who developed diarrhoea after three days of starting antibiotics by ELISA based method for detection of Toxin A/B. Results: Out of 131 stool samples analysed, 6 samples (4.58%)were found to be positive for toxin A/B. Correlation between use of third generation cephalosporin and toxin positivity was found to be insignificant. Significant correlation was found between use of chemotherapeutic agents and toxin positivity. It was also found that advanced age was also significant risk factor for development of CDAD. Conclusion: The present study proves that Cdifficile should be kept in mind as an etiological agent in cases of antibiotic associated diarrhoea. Risk factors include advancing age, use of chemotherapeutic agents and antibiotic exposure. To prevent C difficile infection, unnecessary use of antibiotics should be stopped and screening of stools for Toxin analysis in cases of antibiotic associated diarrhoea should be done so that it can be diagnosed and treatment isstarted at the earliest.

Clostridium difficile in Antibiotic-Associated Diarrhoea and Detection of Toxin Producing Strains in a Tertiary Care Hospital in Western Maharashtra.

Background: Rampant and injudicious use of broadspectrum antibiotic in hospitalized patients hasincreased the incidence of Clostridium difficileAssociated Diarrhea (CDAD). In recent years,Clostridium difficile Infection (CDI) has become morefrequent, severe, and difficult to treat. Aim andObjective: A prospective, study was conducted toisolate C. difficile in Antibiotic-associated Diarrhoea(AAD) and to detect toxin producing strains of C.difficile from faecal samples of patients suspected tohave CDI. Material and Methods: A total of 111hospitalized patients who developed diarrhoea after>72 hours of admission and suspected of CDI wereenrolled for investigation. The samples were subjectedto anaerobic culture and toxin assay. Results: The totalsample size of the study was 111 patients who werehaving antibiotic associated diarrhoea. Majority of thepatients were from the age group 21-30 years and 41-50 years i.e., 23 (20.7%). Males 64 (57.7%) wereaffected more as compared to females 47 (42.3%).Third generation cephalosporins were the mostcommon group of antibiotics associated with bothAAD 36 (32.4%) and CDAD 9 (42.85%) cases,followed by carbapenem fluroquinolones incombination 3 (12.5%). Culture positivity was seen in12 (10.81%) of the 111 stool samples and 39 (35.13%)were toxin producers. Conclusion: The use of severalmedications was found to be associated with anincreased risk of CDAD. The only way to reduce Cl.difficile infection is to judiciously use antibiotics,strictly adhere to antibiotic policy and to give primeimportance to strict infection control measures.

Comparison between the two-step and the three-step algorithms for the detection of toxigenic Clostridium difficile.

Purpose: To evaluate usefulness of applying either the two-step algorithm (Ag-EIAs and CCNA) or the three-step algorithm (all three assays) for better confirmation of toxigenic Clostridium difficile. The antigen enzyme immunoassays (Ag-EIAs) can accurately identify the glutamate dehydrogenase antigen of toxigenic and nontoxigenic Clostridium difficile. Therefore, it is used in combination with a toxin-detecting assay [cell line culture neutralization assay (CCNA), or the enzyme immunoassays for toxins A and B (TOX-A/BII EIA)] to provide specific evidence of Clostridium difficile-associated diarrhoea. Materials and Methods: A total of 151 nonformed stool specimens were tested by Ag-EIAs, TOX-A/BII EIA, and CCNA. All tests were performed according to the manufacturer's instructions and the results of Ag-EIAs and TOX-A/BII EIA were read using a spectrophotometer at a wavelength of 450 nm. Results: A total of 61 (40.7%), 38 (25.3%), and 52 (34.7%) specimens tested positive with Ag-EIA, TOX-A/BII EIA, and CCNA, respectively. Overall, the sensitivity, specificity, negative predictive value, and positive predictive value for Ag-EIA were 94%, 87%, 96.6%, and 80.3%, respectively. Whereas for TOX-A/BII EIA, the sensitivity, specificity, negative predictive value, and positive predictive value were 73.1%, 100%, 87.5%, and 100%, respectively. With the two-step algorithm, all 61 Ag-EIAs-positive cases required 2 days for confirmation. With the three-step algorithm, 37 (60.7%) cases were reported immediately, and the remaining 24 (39.3%) required further testing by CCNA. By applying the two-step algorithm, the workload and cost could be reduced by 28.2% compared with the three-step algorithm. Conclusions: The two-step algorithm is the most practical for accurately detecting toxigenic Clostridium difficile, but it is time-consuming.

Clostridium difficile associated diarrhea: new rules for an old game.

C.difficile associated diarrhea (CDAD) is now considered to be one of the commonest causes of nosocomial diarrhea. CDAD, once considered to be a “nuisance” disease, has lately become a “killer” disease with appearance of a hypervirulent strain, toxinotype III. Although the incidence and severity of CDAD have increased in the western world especially in health care settings; it still is under-recognized in India and Asia. Any episode of diarrhea with fever and leucocytosis in a patient on some antibiotics in a health care setting is strong pointer towards presence of CDAD. Clinical suspicion is usually confirmed by ELISA based C. difficile toxin assays in the stool sample. The aim of therapy is to restore normal colonic microflora, resulting in the elimination of C. difficile. Treatment of C.difficile needs to be individualized depending on the severity of the disease and patient characteristics. Majority of patients will require antibiotic therapy and, whenever possible, discontinuation of the predisposing antibiotics. Metronidazole and vancomycin are the mainstay of the treatment of CDAD, as both these agents are highly active against all strains of pathogenic C.difficile. Neither of these drugs is however effective for the carrier state of C. difficile. Approximately 15%-30% of patients experience a symptomatic recurrence after discontinuation of antibiotics. Control of health care associated CDAD involves a range of primarily preventive measures including proper hand hygiene, use of personal protective equipment, environmental decontamination, isolation or cohort nursing and adequate treatment of CDAD cases.

Established and potential risk factors for clostridum difficile infection.

Clostridium difficile is the aetiological agent for almost all cases of pseudo membranous colitis and 15-25% of antibiotic associated diarrhoea. In recent years, C. difficile associated disease (CDAD) has been increasing in frequency and severity due to the emergence of virulent strains. Severe cases of toxic mega colon may be associated with mortality rates of 24-38%. The prevalence of CDAD is global and the incidence varies considerably from place to place. In the initial stages of its discovery, C. difficile infection was regarded mainly as an outcome of antibiotic intake and not as a life threatening disease. Intervention by man has produced conditions making C. difficile a significant cause of morbidity and mortality. The recent outbreak of CDAD in Quebec has sent the alarm bells ringing. Apart from a threefold increase in the incidence of CDAD, clinicians have also reported a higher number of cases involving toxic mega colon, colectomy or death. Among all the risk factors, inclusive of the host and the environmental factors, antibiotics are the most important ones. Surgical patients comprise 55-75% of all patients with CDAD due to the fact that perioperative prophylaxis requires the use of antibiotics. However, other drugs such as immunosuppressants and proton pump inhibitors are also important risk factors. Thus CDAD is a growing nosocomial and public health challenge. Additionally, the recognition of community acquired CDAD signals the presence of several risk factors. In this review, the established and potential risk factors of CDAD, along with the epidemiology, diagnostic modalities, management and preventive measures of the disease have been elaborated.