An Outbreak of Clostridium difficile Ribotype 027 Associated with Length of Stay in the Intensive Care Unit and Use of Selective Decontamination of the Digestive Tract: A Case Control Study

• Published in: PloS one Vol. 11; no. 8; p. e0160778
• Main Authors: van Beurden, Yvette H, Dekkers, Olaf M, Bomers, Marije K, Kaiser, Annie M, van Houdt, Robin, Knetsch, Cornelis W, Girbes, Armand R J, Mulder, Chris J J, Vandenbroucke-Grauls, Christina M J E
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 17.08.2016; Public Library of Science (PLoS)
• Subjects: Aged; Aged, 80 and over; Antibiotics; Bacteria; Biology and Life Sciences; Case-Control Studies; Clostridium difficile; Clostridium difficile - classification; Clostridium difficile - genetics; Clostridium infections; Clostridium Infections - epidemiology; Clostridium Infections - microbiology; Clostridium Infections - mortality; Comorbidity; Complications and side effects; Control methods; Cross Infection - epidemiology; Cross Infection - microbiology; Cross Infection - mortality; Decontamination; Decontamination - methods; Diagnosis; Diarrhea; Digestive tract; Disease control; Disease Outbreaks; Dosage and administration; Drug therapy; Epidemics; Epidemiology; Female; Gastroenterology; Gastrointestinal tract; Gastrointestinal Tract - microbiology; Gene sequencing; Genomes; Hepatology; Hospitals; Hospitals, University; Humans; Incidence; Infections; Intensive care; Intensive Care Units; Length of Stay; Male; Medical treatment; Medicine and Health Sciences; Microbiology; Microbiota; Middle Aged; Mortality; Netherlands - epidemiology; Outbreaks; Patients; Physiology; Research and Analysis Methods; Ribotyping; Risk Factors; Systematic review; Netherlands; France
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0160778

An outbreak of Clostridium difficile ribotype 027 infection (CDI) occurred at an university hospital, involving 19 departments. To determine what hospital-associated factors drove the outbreak of this particular strain we performed a case-control study. Cases (n = 79), diagnosed with CDI due to C. difficile ribotype 027 were matched for age and treating medical specialty to four control patients (n = 316). Patients diagnosed with CDI due to other ribotypes were included as a second control group. A random selection of C. difficile ribotype 027 strains (n = 10) was genotyped by Whole Genome Sequencing (WGS). WGS showed the outbreak was likely caused by a single strain of C. difficile (two or less single-nucleotide variants between isolates). Ninety-five percent of cases had used antibiotics, compared to 56% of controls. Previous admission to the intensive care unit (ICU) (OR: 2.4, 95% CI 1.0-5.6), longer length of stay (LOS), and recent hospital admission were associated with CDI ribotype 027. Cases were less likely to have been admitted to a ward with a known isolated CDI patient (OR: 0.2, 95% CI 0.1-0.6). Analysis of patients who stayed at the ICU (35 cases; 51 controls), indicated that the use of selective decontamination of the digestive tract (SDD) and a longer LOS in the ICU were associated with CDI risk. In this large outbreak, any antibiotic use, including SDD use, appeared as a prerequisite for acquisition of the outbreak strain. The role of use of SDD and prolonged stay on the ICU could not be disentangled, but both factors can play a biologically plausible role in C. difficile acquisition and infection.