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
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. d...
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| Published in | PloS one Vol. 11; no. 8; p. e0160778 |
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| Main Authors | , , , , , , , , |
| Format | Journal Article |
| Language | English |
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Public Library of Science
17.08.2016
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| Abstract | 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. |
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| AbstractList | 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). Background 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. Methods 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). Findings 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. Interpretation 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. BACKGROUNDAn 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.METHODSCases (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).FINDINGSWGS 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.INTERPRETATIONIn 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. Background 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. Methods 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). Findings 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. Interpretation 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. 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. 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. |
| Audience | Academic |
| Author | van Beurden, Yvette H Mulder, Chris J J Knetsch, Cornelis W Vandenbroucke-Grauls, Christina M J E van Houdt, Robin Kaiser, Annie M Bomers, Marije K Girbes, Armand R J Dekkers, Olaf M |
| AuthorAffiliation | 1 Department of Medical Microbiology and Infection Control, VU University medical center, Amsterdam, The Netherlands 4 Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands 2 Department of Gastroenterology and Hepatology, VU University medical center, Amsterdam, The Netherlands Cleveland Clinic, UNITED STATES 7 Department of Intensive Care, VU University medical center, Amsterdam, The Netherlands 6 Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands 3 Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands 5 Department of Internal Medicine, VU University medical center, Amsterdam, The Netherlands |
| AuthorAffiliation_xml | – name: 2 Department of Gastroenterology and Hepatology, VU University medical center, Amsterdam, The Netherlands – name: Cleveland Clinic, UNITED STATES – name: 7 Department of Intensive Care, VU University medical center, Amsterdam, The Netherlands – name: 6 Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands – name: 3 Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands – name: 5 Department of Internal Medicine, VU University medical center, Amsterdam, The Netherlands – name: 1 Department of Medical Microbiology and Infection Control, VU University medical center, Amsterdam, The Netherlands – name: 4 Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands |
| Author_xml | – sequence: 1 givenname: Yvette H surname: van Beurden fullname: van Beurden, Yvette H organization: Department of Gastroenterology and Hepatology, VU University medical center, Amsterdam, The Netherlands – sequence: 2 givenname: Olaf M surname: Dekkers fullname: Dekkers, Olaf M organization: Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands – sequence: 3 givenname: Marije K surname: Bomers fullname: Bomers, Marije K organization: Department of Internal Medicine, VU University medical center, Amsterdam, The Netherlands – sequence: 4 givenname: Annie M surname: Kaiser fullname: Kaiser, Annie M organization: Department of Medical Microbiology and Infection Control, VU University medical center, Amsterdam, The Netherlands – sequence: 5 givenname: Robin surname: van Houdt fullname: van Houdt, Robin organization: Department of Medical Microbiology and Infection Control, VU University medical center, Amsterdam, The Netherlands – sequence: 6 givenname: Cornelis W surname: Knetsch fullname: Knetsch, Cornelis W organization: Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands – sequence: 7 givenname: Armand R J surname: Girbes fullname: Girbes, Armand R J organization: Department of Intensive Care, VU University medical center, Amsterdam, The Netherlands – sequence: 8 givenname: Chris J J surname: Mulder fullname: Mulder, Chris J J organization: Department of Gastroenterology and Hepatology, VU University medical center, Amsterdam, The Netherlands – sequence: 9 givenname: Christina M J E surname: Vandenbroucke-Grauls fullname: Vandenbroucke-Grauls, Christina M J E organization: Department of Medical Microbiology and Infection Control, VU University medical center, Amsterdam, The Netherlands |
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| CitedBy_id | crossref_primary_10_1017_ice_2017_89 crossref_primary_10_1177_1757177416683264 crossref_primary_10_1186_s13756_017_0181_4 crossref_primary_10_1016_j_jhin_2016_12_019 crossref_primary_10_1016_j_jhin_2020_03_019 crossref_primary_10_1097_QCO_0000000000000387 crossref_primary_10_1021_acs_jnatprod_2c00120 crossref_primary_10_1016_j_jhin_2020_07_034 crossref_primary_10_1177_1756283X17690480 crossref_primary_10_1016_j_cmi_2017_07_025 crossref_primary_10_1017_ice_2018_163 crossref_primary_10_7189_jogh_07_010417 |
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| Title | 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 |
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