Clinical Profile of Clostridium Difficile Associated Diarrhea: A study from Tertiary Care Centre of South India

Abstract

Background: Clostridium difficile infection (CDI) is a common cause of diarrhea in hospitalized patients worldwide however it is uncommonly reported from Indian hospitals and clinical profile of Indian patients with CDI is not well studied. Methods: This was a retrospective study done in a tertiary care centre of South India between March 2016 and May 2017. Case records of all patients for whom stool samples were sent for either C. difficile toxin assay or GeneXpert C. difficile were analysed. Coloured immunoassay (CerTech) was used for detecting Glutamate dehydrogenase (GDH) and Toxin A and B and nucleic acid amplification assay (Xpert, Cepheid) were used. Results: A total of 112 were analyzed, out of which 18 were positive and negative cases (n = 94) were taken as controls. Prevalence of CDI was 16%. Presence of fever (OR = 8.5), tenesmus (OR = 8.5), hematochezia (OR = 4.5), cramps (OR = 8.27), use of immunosuppressive agents (OR = 3.62) and duration of antibiotics (7.38±6.50 vs 4.54±6.57 days; p=0.019) was significantly higher among cases. Conclusion: Although the prevalence of CDI is low in India compared to the west, it still contributes to significant morbidity in hospitalized patients as it is responsible for more than 1 in 6 cases of diarrhea in hospitalized patients. Fever, cramps, tenesmus, hematochezia, use of immunosuppressants and antibiotic therapy of more than 7 days suggest a diagnosis of CDI, and should trigger testing and treatment. Outcomes are good with appropriate therapy.

Systematic Literature Review on Burden of Clostridioides difficile Infection in India

“…The majority of the studies have shown the occurrence of CDI in already hospitalized patients, 16-19,21,24,26,27,29-31,33-37,39,42,46 indicating hospitalization as one of the key risk factors for developing CDI.…”

“…Three studies involved only adult patients, and the prevalence of CDI was reported to be 3.4% in patients with ulcerative colitis and intestinal infection, 28 16% in patients with hospital-acquired diarrhea, 27 and 18.06% in HIV-seropositive subjects with diarrhea. 40 All patients with reported hospitalacquired diarrhea were under antibiotic therapy (CDT positive as well as CDT negative), 27 whereas the status of prior antibiotic therapy is poorly defined in the remaining studies in the adult population. 28,40 Unadjusted statistical analysis was performed to investigate the association between prevalence of CDI and different geographical regions of the country.…”

“…A total of 31 articles reported data on the prevalence of CDI in different hospitals across India. 16-46 Despite heterogeneity in the diagnostic approach for testing CDI between the studies, most of the studies confirmed CDI based on clinical diagnosis (“diarrhea”) and laboratory findings (“toxin positivity”). Heterogeneity exists in the study patient population in terms of age and comorbidities.…”

“…A total of 22 studies reported the prior use of antibiotics in the population that developed CDI. [17][18][19][20]22,24,25,[27][28][29][30][31]34,40,42,43 Three studies have reported third-generation cephalosporin as a predominant risk factor for CDI development. 26,34,42 Figure 2 highlights the studies where antibiotic usage was highest at the time of CDI diagnosis.…”

“…Segar et al 22 reported a 4.7 times higher risk of developing CDI associated with the use of doxycycline among glutamate dehydrogenase (GDH)-positive patients versus GDH-negative patients. The majority of the studies have shown the occurrence of CDI in already hospitalized patients, [16][17][18][19]21,24,26,27,[29][30][31][33][34][35][36][37]39,42,46 indicating hospitalization as one of the key risk factors for developing CDI.…”