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1.
Clin Microbiol Infect ; 25(5): 607-612, 2019 May.
Article in English | MEDLINE | ID: mdl-30076972

ABSTRACT

OBJECTIVES: Clostridium difficile infections (CDI) account for 1.5% of diarrhoeic episodes in patients attending a general practitioner in the Netherlands, but its sources are unknown. We searched for community clusters to recognize localized point sources of CDI. METHODS: Between October 2010 and February 2012, a community-based prospective nested case-control study was performed in three laboratories in the Netherlands with a study population of 2 810 830 people. Bernoulli spatial scan and space-time permutation models were used to detect spatial and/or temporal clusters of CDI. In addition, a multivariate conditional logistic regression model was constructed to test livestock exposure as a supposed risk factor in CDI patients without hospital admission within the previous 12 weeks (community-acquired (CA) CDI). RESULTS: In laboratories A, B and C, 1.3%, 1.8% and 2.1% of patients with diarrhoea tested positive for CDI, respectively. The mean age of CA-CDI patients (n = 124) was 49 years (standard deviation, 22.6); 64.5% were female. No spatial or temporal clusters of CDI cases were detected compared to C. difficile-negative diarrhoeic controls. Except for one false-positive signal, no spatiotemporal interaction amongst CDI cases was found. Livestock exposure was not related to CA-CDI (odds ratio, 0.99; 95% confidence interval, 0.44-2.24). Ten percent of CA-CDIs was caused by PCR ribotype 078, spatially dispersed throughout the study area. CONCLUSIONS: The absence of clusters of CDI cases in a community cohort of diarrhoeic patients suggests a lack of localized point sources of CDI in the living environment of these patients.


Subject(s)
Clostridium Infections/epidemiology , Cluster Analysis , Community-Acquired Infections/epidemiology , Environmental Exposure , Livestock , Adolescent , Adult , Aged , Aged, 80 and over , Animals , Case-Control Studies , Child , Child, Preschool , Female , Humans , Male , Middle Aged , Netherlands , Prospective Studies , Risk Factors , Spatio-Temporal Analysis , Young Adult
2.
Clin Microbiol Infect ; 20(12): O1067-74, 2014 Dec.
Article in English | MEDLINE | ID: mdl-25040463

ABSTRACT

Clostridium difficile infections (CDIs) are frequent in hospitals, but also seem to increase in the community. Here, we aim to determine the incidence of CDI in general practice and to evaluate current testing algorithms for CDI. Three Dutch laboratories tested all unformed faeces (12,714) for C. difficile when diagnostic testing (for any enteric pathogen) was requested by a general practitioner (GP). Additionally, a nested case-control study was initiated, including 152 CDI patients and 304 age and sex-matched controls. Patients were compared using weighted multivariable logistic regression. One hundred and ninety-four samples (1.5%) were positive for C. difficile (incidence 0.67/10,000 patient years). This incidence was comparable to that of Salmonella spp. Compared with diarrhoeal controls, CDI was associated with more severe complaints, underlying diseases, antibiotic use and prior hospitalization. In our study, GPs requested a test for C. difficile in 7% of the stool samples, thereby detecting 40% of all CDIs. Dutch national recommendations advise testing for C. difficile when prior antibiotic use or hospitalization is present (18% of samples). If these recommendations were followed, 61% of all CDIs would have been detected. In conclusion, C. difficile is relatively frequent in general practice. Currently, testing for C. difficile is rare and only 40% of CDI in general practice is detected. Following recommendations that are based on traditional risk factors for CDI, would improve detection of CDI.


Subject(s)
Clostridioides difficile/isolation & purification , Clostridium Infections/diagnosis , Diarrhea/diagnosis , Diarrhea/microbiology , Adolescent , Adult , Aged , Aged, 80 and over , Case-Control Studies , Child , Child, Preschool , Clostridium Infections/epidemiology , Clostridium Infections/microbiology , Clostridium Infections/pathology , Diarrhea/epidemiology , Diarrhea/pathology , Female , General Practice , Humans , Incidence , Male , Middle Aged , Netherlands , Young Adult
3.
Clin Microbiol Infect ; 20(5): O301-8, 2014 May.
Article in English | MEDLINE | ID: mdl-24188103

ABSTRACT

Clostridium difficile infections (CDIs) are a common cause of antibiotic-associated diarrhoea and associated with CDI-related mortality in c. 10%. To date, there is no prediction model in use that guides clinicians to identify patients at high risk for complicated CDI. From 2006 to 2009, nine Dutch hospitals included hospitalized CDI patients in a prospective cohort. Potential predictors of a complicated course (ICU admission, colectomy or death due to CDI) were evaluated in uni- and multivariate logistic regression. A score was constructed that was internally validated by bootstrapping. Furthermore, a pilot external validation was performed. Twelve per cent of 395 CDI patients had a complicated course within 30 days after diagnosis. Age (≥85 years, OR 4.96; 50-84 years, 1.83), admission due to diarrhoea (OR 3.27), diagnosis at the ICU department (OR 7.03), recent abdominal surgery (OR 0.23) and hypotension (OR 3.25) were independent predictors of a complicated course. These variables were used to construct a prediction model. A score subsequently classified patients into high risk (39% with a complicated course), intermediate (16%), low (5%) or virtually no risk of experiencing a complicated course. The score performed well after internal validation (AUC 0.78) and a pilot external validation among 139 patients showed similar good performance (AUC 0.73). We present an easy-to-use, clinically useful risk score that is capable of categorizing CDI patients according to their outcome. Because classification is available at diagnosis, it could have major implications for treatment choice.


Subject(s)
Clostridioides difficile , Decision Support Techniques , Enterocolitis, Pseudomembranous/complications , Abdomen/surgery , Age Factors , Aged , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Area Under Curve , Colectomy , Critical Care , Diarrhea/etiology , Enterocolitis, Pseudomembranous/microbiology , Enterocolitis, Pseudomembranous/mortality , Enterocolitis, Pseudomembranous/therapy , Female , Humans , Hypotension/complications , Male , Middle Aged , Predictive Value of Tests , Prognosis , Prospective Studies , ROC Curve , Risk Assessment/methods
4.
Clin Microbiol Infect ; 18(7): 635-45, 2012 Jul.
Article in English | MEDLINE | ID: mdl-22536816

ABSTRACT

Clostridium difficile infections (CDIs) are traditionally seen in elderly and hospitalized patients who have used antibiotic therapy. In the community, CDIs requiring a visit to a general practitioner are increasingly occurring among young and relatively healthy individuals without known predisposing factors. C. difficile is also found as a commensal or pathogen in the intestinal tracts of most mammals, and various birds and reptiles. In the environment, including soil and water, C. difficile may be ubiquitous; however, this is based on limited evidence. Food products such as (processed) meat, fish and vegetables can also contain C. difficile, but studies conducted in Europe report lower prevalence rates than in North America. Absolute counts of toxigenic C. difficile in the environment and food are low, however the exact infectious dose is unknown. To date, direct transmission of C. difficile from animals, food or the environment to humans has not been proven, although similar PCR ribotypes are found. We therefore believe that the overall epidemiology of human CDI is not driven by amplification in animals or other sources. As no outbreaks of CDI have been reported among humans in the community, host factors that increase vulnerability to CDI might be of more importance than increased exposure to C. difficile. Conversely, emerging C. difficile ribotype 078 is found in high numbers in piglets, calves, and their immediate environment. Although there is no direct evidence proving transmission to humans, circumstantial evidence points towards a zoonotic potential of this type. In future emerging PCR ribotypes, zoonotic potential needs to be considered.


Subject(s)
Clostridioides difficile/isolation & purification , Clostridium Infections/transmission , Clostridium Infections/veterinary , Community-Acquired Infections/microbiology , Community-Acquired Infections/transmission , Zoonoses/microbiology , Zoonoses/transmission , Animals , Cattle , Cattle Diseases/microbiology , Cattle Diseases/transmission , Clostridioides difficile/classification , Clostridioides difficile/genetics , Environmental Microbiology , Food Microbiology , Gastrointestinal Tract/microbiology , Genotype , Humans , Molecular Epidemiology , Molecular Typing , Swine , Swine Diseases/microbiology , Swine Diseases/transmission
5.
Clin Microbiol Infect ; 18(8): 778-84, 2012 Aug.
Article in English | MEDLINE | ID: mdl-21919997

ABSTRACT

The presence and characteristics of Clostridium difficile were investigated in 839 faecal samples from seven different animal species in the Netherlands. The number of positive samples ranged from 3.4% (cattle) to 25.0% (dogs). Twenty-two different PCR ribotypes were identified. Among 96 isolates, 53% harboured toxin genes. All C. difficile isolates from pigs, cattle and poultry were toxinogenic, whereas the majority of isolates from pet animals consisted of non-toxinogenic PCR ribotypes 010 and 039. Ribotype 012 was most prevalent in cattle and ribotype 078 in pigs. No predominant ribotypes were present in horse and poultry samples. Overall, PCR ribotypes 012, 014 and 078 were the most frequently recovered toxinogenic ribotypes from animal samples. Comparison with human isolates from the Dutch Reference Laboratory for C. difficile at Leiden University Medical Centre (LUMC) showed that these types were also recovered from human hospitalized patients in 2009/2010, encompassing 0.8%, 11.4% and 9.8% of all isolates, respectively. Application of multiple-locus variable-number tandem-repeat analysis indicated a genotypic relation of animal and human ribotype 078 strains, but a clear genotypic distinction for ribotypes 012 and 014. We conclude that toxinogenic C. difficile PCR ribotypes found in animals correspond to PCR ribotypes associated with human disease in hospitalized patients in the Netherlands. Contrary to PCR ribotype 078, significant genetic differences were observed between animal and human PCR ribotype 012 and 014 isolates.


Subject(s)
Clostridioides difficile/classification , Clostridioides difficile/isolation & purification , Clostridium Infections/veterinary , Animals , Cattle , Clostridium Infections/epidemiology , Clostridium Infections/microbiology , Cluster Analysis , Dogs , Feces/microbiology , Genotype , Horses , Humans , Minisatellite Repeats , Netherlands/epidemiology , Poultry , Prevalence , Ribotyping , Swine
6.
Epidemiol Infect ; 140(10): 1787-93, 2012 Oct.
Article in English | MEDLINE | ID: mdl-22152928

ABSTRACT

Between 2000 and 2009, the total number of patients with Clostridium difficile infections increased considerably in Southeastern Germany. A clear seasonality was observed with a higher number of affected patients occurring in the winter months (January-March). Moxifloxacin and erythromycin-resistant C. difficile PCR ribotypes 001 (72%) and 027 (4·6%) were the most commonly isolated strains.


Subject(s)
Clostridioides difficile/isolation & purification , Clostridium Infections/epidemiology , Seasons , Anti-Bacterial Agents/pharmacology , Aza Compounds/pharmacology , Cluster Analysis , Drug Resistance, Bacterial , Erythromycin/pharmacology , Fluoroquinolones , Genotype , Germany/epidemiology , Humans , Moxifloxacin , Quinolines/pharmacology , Ribotyping
7.
Eur J Clin Microbiol Infect Dis ; 30(4): 587-93, 2011 Apr.
Article in English | MEDLINE | ID: mdl-21194003

ABSTRACT

The purpose of this investigation was to study risk factors for Clostridium difficile infection (CDI) in an endemic setting. In a 34-month prospective case-control study, we compared the risk factors and clinical characteristics of all consecutively diagnosed hospitalised CDI patients (n = 93) with those of patients without diarrhoea (n = 76) and patients with non-CDI diarrhoea (n = 64). The incidence of CDI was 17.5 per 10,000 hospital admissions. C. difficile polymerase chain reaction (PCR) ribotype 014 was the most frequently found type (15.9%), followed by types 078 (12.7%) and 015 (7.9%). Independent risk factors for endemic CDI were the use of second-generation cephalosporins, previous hospital admission and previous stay at the intensive care unit (ICU). The use of third-generation cephalosporins was a risk factor for diarrhoea in general. We found no association of CDI with the use of fluoroquinolones or proton pump inhibitors (PPIs). The overall 30-day mortality among CDI patients, patients without diarrhoea and patients with non-CDI diarrhoea was 7.5%, 0% and 1.6%, respectively. In this endemic setting, risk factors for CDI differed from those in outbreak situations. Some risk factors that have been ascribed to CDI earlier were, in this study, not specific for CDI, but for diarrhoea in general. The 30-day mortality among CDI patients was relatively high.


Subject(s)
Academic Medical Centers/statistics & numerical data , Clostridioides difficile/isolation & purification , Clostridium Infections/epidemiology , Endemic Diseases , Enterocolitis, Pseudomembranous/epidemiology , Aged , Anti-Bacterial Agents/therapeutic use , Case-Control Studies , Cephalosporins/therapeutic use , Clostridioides difficile/classification , Clostridioides difficile/genetics , Clostridium Infections/microbiology , Clostridium Infections/mortality , Clostridium Infections/physiopathology , Diarrhea/epidemiology , Diarrhea/microbiology , Enterocolitis, Pseudomembranous/microbiology , Enterocolitis, Pseudomembranous/mortality , Enterocolitis, Pseudomembranous/physiopathology , Female , Hospitalization , Humans , Incidence , Male , Netherlands/epidemiology , Prospective Studies , Risk Factors
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