Community-associated Clostridium difficile infection among older people in Tayside, Scotland, is associated with antibiotic exposure and care home residence: cohort study with nested case-control

Abstract

Objectives: To estimate the risks of community-associated Clostridium difficile infection (CA-CDI) among the population aged ≥65 years associated with antibiotic exposure and care home residence. Population and methods:We linked cases from a prospective study in Tayside, Scotland from 1 November 2008 to 31 October 2009 to population datasets to conduct a cohort study and a nested, matched (1 : 10 by age and gender) case-control study.Results: There were 79039 eligible residents. CA-CDI incidence was 20.3/10 000 person years. In the cohort study, after adjustment, we found a significantly increasing risk of CA-CDI with increasing age and comorbidity, prior hospital admission, care home residence [hazard ratio (HR) 1.96, 95% CI 1.14-3.34] and baseline antibiotic exposure (1.94, 1.35-2.77). In separate adjusted models, '4C' antibiotics (clindamycin, co-amoxiclav, cephalosporins, ciprofloxacin; 2.75, 1.78-4.26) and fluoroquinolones (3.33, 1.95-5.67) had higher associated risks. We matched 62 CA-CDI cases without recent (prior 3 months) hospital admission to 620 controls. In adjusted logistic regression models, exposure to any antibiotics increased the risk of CA-CDI (OR 6.04,). Exposure to 4C antibiotics or fluoroquinolones had higher associated risks: adjusted OR 11.60 (95% CI 5.57 -24.15) and 13.04 (4.91 -34.64), respectively. Risk of CA-CDI increased with cumulative antibiotic exposure. Subgroup analysis of 42 cases with C. difficile cultured and 420 controls amplified all associations between antibiotic exposure and CA-CDI. Care home residence independently increased the risk of CA-CDI in all models. Conclusions:Our results have two important implications. First, they validate the classification of 4C antibiotics and fluoroquinolones in primary care as high risk for CA-CDI. Second, they demonstrate the importance of prior antibiotic exposure and place of residence for risk assessment by primary care prescribers.

Infections and antimicrobial use among institutionalized residents in Hungary: Increasing need of microbiological surveillance

“…National result showed that the prevalence of antimicrobial use was lower than the prevalence of infections, thus the overuse of antimicrobials is not common in participating LTCFs. Although prescription of quinolone antibacterials was frequent (34.2%) in LTCFs, which can lead the increased presence of infections caused by Clostridium diffi cile and other antimicrobial resistant pathogens [22][23][24][25][26][27]. This result is similar to several overseas studies that quinolones are the most frequently prescribed antibacterials in LTCFs [20][21][22][23][24][25][26][27].…”

Clostridium difficile infection and inflammatory bowel disease

“…Clindamycin was initially associated with CDI, but more recently, fluoroquinolones, widely used in IBD patients, have become the most common risk factor for CDI (4). The mechanism through which the use of antibiotics leads to increased risk for CDI development is the disruption of normal intestinal flora and the subsequent proliferation of C. difficile.…”

“…Illustratively, in USA alone, hospital discharges with CDI as the main diagnosis registered a 237% increase from 2000 to 2009, and accounted for hospital mortality rate similar to that of gastrointestinal bleeding (2), with healthcare costs estimated between 1.2 and 3 billion US dollars each year (3). In addition to broad-spectrum antimicrobial therapy, which is the most widely recognized causative factor for CDI (4), other potential risk factors, such as advanced age, prolonged hospitalization, chemotherapy, immunosuppression, multiple co-morbidities, hypoalbuminemia, renal insufficiency, use of proton pump inhibitors, and the emergence of a hypervirulent strain of the bacterium known as NAP1 (North American pulsed field type1) in some North-American and European areas, have been identified to explain the increased incidence of CDI (5-7).…”

Clostridium difficile infection in elderly nursing home residents

“…Furthermore, in a cohort study of community-associated CDI infection among older people and the relationship between infection, antibiotic exposure, and care home residence, authors reported an increased mortality among subjects that whose infections were healthcare-onset, but not among CDI cases in the community [2]. Similarly, in the study of Garg et al [15], the highest mortality was found among C. difficile infection cases in hospital (9.4%) while the percentage of deaths was lower in long-term care facility CDI cases (7.6%) and in community acquired infections (2.3%).…”