Poor Infection Control, Not Fluoroquinolones, Likely to Be Primary Cause of Clostridium difficile-Associated Diarrhea Outbreaks in Quebec

Weiss, Karl Heinz

doi:10.1086/500268

Cited by 26 publications

(20 citation statements)

References 10 publications

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“…Appropriate control measures to curtail outbreaks of CD infection have been debated [27][28][29]. Alcohol-based hand sanitizers are thought to be ineffective in controlling CD infection transmission, because they have poor activity against CD spores [30].…”

Section: Discussionmentioning

confidence: 99%

Control of an Outbreak of Infection with the Hypervirulent Clostridium difficile BI Strain in a University Hospital Using a Comprehensive "Bundle" Approach

Muto

Blank²,

Marsh³

et al. 2007

Clinical Infectious Diseases

223

150

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Background. In June 2000, the hospital-acquired Clostridium difficile (CD) infection rate in our hospital (University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, PA) increased to 10.4 infections per 1000 hospital discharges (HDs); the annual rate increased from 2.7 infections per 1000 HDs to 7.2 infections per 1000 HDs and was accompanied by an increase in the frequency of severe outcomes. Forty-seven (51%) of 92 HA CD isolates in 2001 were identified as the "epidemic BI strain." A comprehensive CD infection control "bundle" was implemented to control the outbreak of CD infection.Methods. The CD infection control bundle consisted of education, increased and early case finding, expanded infection-control measures, development of a CD infection management team, and antimicrobial management.Process measures, antimicrobial usage, and hospital-acquired CD infection rates were analyzed, and CD isolates were typed.Results. The rates of compliance with hand hygiene and isolation were 75% and 68%, respectively. The CD management team evaluated a mean of 31 patients per month (11% were evaluated for moderate or severe disease). Use of antimicrobial therapy associated with increased CD infection risk decreased by 41% during the period 2003-2005 (). The aggregate rate of CD infection during the period 2001-2006 decreased to 4.8 infections per 1000 P ! .001 HDs (odds ratio, 2.2; 95% confidence interval, 1.4-3.1;) and by 2006, was 3.0 infections per 1000 HDs, a P ! .001 rate reduction of 71% (odds ratio, 3.5; 95% confidence interval, 2.3-5.4;). During the period 2000-2001, P ! .001 the proportion of severe CD cases peaked at 9.4% (37 of 393 CD infections were severe); the rate decreased to 3.1% in 2002 and further decreased to 1.0% in 2006-a 78% overall reduction (odds ratio, 20.3; 95% confidence interval, 2.8-148.2; ). In 2005, 13% of CD isolates were type BI (20% were hospital acquired), which represented a P ! .001 significant reduction from 2001 ( ). P ! .001 Conclusions. The outbreak of CD infection with the BI strain in our hospital was controlled after implementing a CD infection control "bundle." Early identification, coupled with appropriate control measures, reduces the rate of CD infection and the frequency of adverse events.

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Section: Discussionmentioning

confidence: 99%

Control of an Outbreak of Infection with the Hypervirulent Clostridium difficile BI Strain in a University Hospital Using a Comprehensive "Bundle" Approach

Muto

Blank²,

Marsh³

et al. 2007

Clinical Infectious Diseases

223

150

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“…For all these reasons, odds ratios for the risk of CDI with individual antibiotics should be treated with caution (Table 1). Given the many potential confounding factors when determining CDI risk, it is not surprising that the use of antibiotics measured at the hospital level may not correlate with the likelihood of occurrence of CDI outbreaks (198,208). When reviewing antibiotic risk data, it is important to distinguish between studies that identify apparent antibiotic risk factors for CDI and those where antimicrobial intervention strategies, typically comprising restrictive prescribing, have been employed to reduce the rate of infection.…”

Section: Antibiotic Risk Factor and Prescribing Intervention Studiesmentioning

confidence: 99%

“…Interestingly, although fluoroquinolones had been identified retrospectively as a significant risk factor during a large outbreak of CDI in Quebec, Canada (155), CDI rates subsequently decreased in association with the antimicrobial restriction of narrow-spectrum (Ϫ21%), expanded-spectrum (Ϫ93%), and broad-spectrum (Ϫ79%) cephalosporins; clindamycin (Ϫ87%); macrolides (Ϫ78%); and ciprofloxacin (Ϫ29%); however, prescribing of respiratory fluoroquinolones (predominantly moxifloxacin) and piperacillin-tazobactam increased by ϩ79% and ϩ114%, respectively (195). It has been suggested that the combined implementation of improved infection control measures and judicious antimicrobial use, as opposed to the restriction of a specific antimicrobial, was responsible for eventually controlling this outbreak (20,208). A recent interesting study examined the risk factors for CDI in cases due to both epidemic (C. difficile NAP1) and nonepidemic strains (95).…”

Section: Antibiotic Risk Factor and Prescribing Intervention Studiesmentioning

confidence: 99%

The Changing Epidemiology of Clostridium difficile Infections

et al. 2010

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SUMMARY The epidemiology of Clostridium difficile infection (CDI) has changed dramatically during this millennium. Infection rates have increased markedly in most countries with detailed surveillance data. There have been clear changes in the clinical presentation, response to treatment, and outcome of CDI. These changes have been driven to a major degree by the emergence and epidemic spread of a novel strain, known as PCR ribotype 027 (sometimes referred to as BI/NAP1/027). We review the evidence for the changing epidemiology, clinical virulence and outcome of treatment of CDI, and the similarities and differences between data from various countries and continents. Community-acquired CDI has also emerged, although the evidence for this as a distinct new entity is less clear. There are new data on the etiology of and potential risk factors for CDI; controversial issues include specific antimicrobial agents, gastric acid suppressants, potential animal and food sources of C. difficile, and the effect of the use of alcohol-based hand hygiene agents.

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“…We may assume that, in addition to the use of fluoroquinolones, the spread of the new strain of Clostridium difficile is associated with breaches in infection control. 46 Infection-control measures should be emphasized and practiced meticulously in neutropenic patients.…”

Section: Infections Caused By Clostridium Difficilementioning

confidence: 99%

Antibiotic prophylaxis in neutropenic patients

Leibovici

Cullen

Bucaneve³

et al. 2006

Cancer

174

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New evidence shows that antibiotic prophylaxis in neutropenic patients reduces mortality, febrile episodes, and bacterial infections. For patients with acute leukemia or those who undergo bone marrow transplantation, prophylaxis with fluoroquinolones diminished the risk of death from any cause by 33% (95% confidence interval [95% CI], 2-54%). Thus, 55 patients who have acute leukemia or who undergo bone marrow transplantation must receive prophylaxis to prevent 1 death. In 4 studies that included patients with solid tumors or lymphoma, prophylaxis reduced the rate of death during the first month (relative risk, 0.51; 95% CI, 0.27-0.97), and 82 patients had to receive prophylaxis to prevent 1 death. The main argument brought against prophylaxis is the induction of resistance. Patients who received prophylaxis did not experience more infections caused by resistant strains than patients in the control group. The recent GIMEMA study was con- N ew evidence shows that antibiotic prophylaxis in neutropenic patients reduces mortality, febrile episodes, and bacterial infections. A systematic review and meta-analysis of randomized controlled trials 1 demonstrated that death from all causes was reduced by 34% (95% confidence interval [95% CI], 21-45%) in neutropenic patients who received any antibiotic prophylaxis and by 40% (95% CI, 17-56%) in patients who received quinolones for prophylaxis. in addition, the occurrence of febrile episodes and bacterial infections decreased significantly (Table 1). Most of the studies that were included in that meta-analysis addressed patients with hematologic malignancies. In the most recent and largest randomized controlled trial that included patients in whom neutropenia was expected to occur for more than 7 days (mainly with acute leukemia and autologous peripheral blood stem cell transplantation), 2 patients who received levofloxacin as prophylaxis had a relative risk (RR) of 0.54 (95% CI, 0.25-1.16) for mortality compared with the placebo group: a Dr. Cullen has received honoraria from Sanofi Aventis.We thank Dr. Vivianne Tjan-Heijnen and Ms. Muriel Debois for supplying us with full data regarding mortality from their study.

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Poor Infection Control, Not Fluoroquinolones, Likely to Be Primary Cause of Clostridium difficile-Associated Diarrhea Outbreaks in Quebec

Cited by 26 publications

References 10 publications

Control of an Outbreak of Infection with the Hypervirulent Clostridium difficile BI Strain in a University Hospital Using a Comprehensive "Bundle" Approach

Control of an Outbreak of Infection with the Hypervirulent Clostridium difficile BI Strain in a University Hospital Using a Comprehensive "Bundle" Approach

The Changing Epidemiology of Clostridium difficile Infections

Antibiotic prophylaxis in neutropenic patients

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