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CC BY-NC-ND 4.0 · J Lab Physicians 2021; 13(04): 346-352
DOI: 10.1055/s-0041-1731944
Original Article

Clostridioides difficile Diarrhea: An Emerging Problem in a South Indian Tertiary Care Hospital

Rachana Kannambath
1   Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Rakhi Biswas
1   Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Jharna Mandal
1   Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Kolar V. Vinod
2   Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Biswajit Dubashi
3   Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Narayanan Parameswaran
4   Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
› Author Affiliations Funding This study was funded by intramural research fund, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
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Abstract

Context Clostridioides difficile infection (CDI) is one of the most common infectious causes of hospital-acquired diarrhea. The actual burden of the disease is underestimated in India due to inadequate diagnostic methods and limited studies conducted.

Aims The aim of this study was to determine the burden and risk factors of CDI among patients with hospital-acquired diarrhea.

Methods and Materials Stool specimen of patients (age > 1 year) with hospital-acquired diarrhea were screened for glutamate dehydrogenase antigen and toxin using an enzyme immunoassay. If both antigen and toxin were present, it was reported as positive for toxigenic CDI. Samples positive for antigen and negative for toxin were further tested with Cepheid GeneXpert assay for detecting the toxin producing gene.

Results Of 75 patients (mean age 36.07 ± 20.79, 64% males), 14 (18.67%) patients were positive for toxigenic Clostridioides difficile (C. difficile) and 3 (4%) patients were nontoxigenic C. difficile. Addition of GeneXpert to the testing algorithm increased the yield of toxin detection in 5/14 patients who were negative by toxin assay. On analysis of risk factors, prolonged hospital stay was found to have significant association (p-value = 0.022). Patients with factors like intensive care unit stay, presence of diabetes mellitus as a comorbidity, and exposure to antibiotics like carbapenems and glycopeptides have been found to have a higher prevalence of CDI.

Conclusions The prevalence of CDI in our population was 18.67% and the major risk factor associated was prolonged hospital stay. The addition of GeneXpert for the detection of toxin gene increased the yield from 12 to 18.68%.

Keywords

Clostridioides difficile infection - hospital-acquired diarrhea - toxin detection


Publication History

Article published online:
09 July 2021

© 2021. The Indian Association of Laboratory Physicians. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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  • References

  • 1 Polage CR, Solnick JV, Cohen SH. Nosocomial diarrhea: evaluation and treatment of causes other than Clostridium difficile. Clin Infect Dis 2012; 55 (07) 982-989
    CrossrefPubMedGoogle Scholar
  • 2 Cohen SH, Gerding DN, Johnson S. et al Society for Healthcare Epidemiology of America; Infectious Diseases Society of America. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31 (05) 431-455
    CrossrefPubMedGoogle Scholar
  • 3 Eze P, Balsells E, Kyaw MH, Nair H. Risk factors for Clostridium difficile infections - an overview of the evidence base and challenges in data synthesis. J Glob Health 2017; 7 (01) 010417
    CrossrefPubMedGoogle Scholar
  • 4 Burnham C-AD, Carroll KC. Diagnosis of Clostridium difficile infection: an ongoing conundrum for clinicians and for clinical laboratories. Clin Microbiol Rev 2013; 26 (03) 604-630
    CrossrefPubMedGoogle Scholar
  • 5 Verma P, Makharia GK. Clostridium difficile associated diarrhea: new rules for an old game. Trop Gastroenterol 2011; 32 (01) 15-24
    PubMedGoogle Scholar
  • 6 Vishwanath S, Singhal A, D’Souza A, Mukhopadhyay C, Varma M, Bairy I. Clostridium difficile infection at a tertiary care hospital in south India. J Assoc Physicians India 2013; 61 (11) 804-806
    PubMedGoogle Scholar
  • 7 Ingle M, Deshmukh A, Desai D. et al Prevalence and clinical course of Clostridium difficile infection in a tertiary-care hospital: a retrospective analysis. Indian J Gastroenterol 2011; 30 (02) 89-93
    CrossrefPubMedGoogle Scholar
  • 8 Chakraborty A, Kar A, Roy S. Changing trends of Clostridium difficile associated diarrhoea (CDAD) in a tertiary care hospital in Kolkata, India. Intensive Care Med Exp 2015; 3 (Suppl. 01) A118
    CrossrefGoogle Scholar
  • 9 Kumar GV, Uma BM. Clostridium difficile: a neglected, but emerging pathogen in India. Arch Clin Microbiol 2015; 6: 2-6
    Google Scholar
  • 10 Segar L, Easow JM, Srirangaraj S, Hanifah M, Joseph NM, Seetha KS. Prevalence of Clostridium difficile infection among the patients attending a tertiary care teaching hospital. Indian J Pathol Microbiol 2017; 60 (02) 221-225
    CrossrefPubMedGoogle Scholar
  • 11 Landry ML, Topal JE, Estis J, Katzenbach P, Nolan N, Sandlund J. High agreement between an ultrasensitive Clostridioides difficile toxin assay and a C. difficile laboratory algorithm utilizing GDH-and-toxin enzyme immunoassays and cytotoxin testing. J Clin Microbiol 2020; 58 (02) e01629-e19
    CrossrefPubMedGoogle Scholar
  • 12 Pollock NR, Banz A, Chen X. et al Comparison of Clostridioides difficile stool toxin concentrations in adults with symptomatic infection and asymptomatic carriage using an ultrasensitive quantitative immunoassay. Clin Infect Dis 2019; 68 (01) 78-86
    PubMedGoogle Scholar
  • 13 Vaishnavi C, Singh M, Mahmood S, Kochhar R. Prevalence and molecular types of Clostridium difficile isolates from faecal specimens of patients in a tertiary care centre. J Med Microbiol 2015; 64 (11) 1297-1304
    CrossrefPubMedGoogle Scholar
  • 14 McDonald LC, Gerding DN, Johnson S. et al Clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66 (07) 987-994
    CrossrefPubMedGoogle Scholar
  • 15 McFarland LV, Ozen M, Dinleyici EC, Goh S. Comparison of pediatric and adult antibiotic-associated diarrhea and Clostridium difficile infections. World J Gastroenterol 2016; 22 (11) 3078-3104
    CrossrefPubMedGoogle Scholar
  • 16 Singh M, Vaishnavi C, Kochhar R, Mahmood S. Toxigenic Clostridium difficile isolates from clinically significant diarrhoea in patients from a tertiary care centre. Indian J Med Res 2017; 145 (06) 840-846
    CrossrefPubMedGoogle Scholar
  • 17 Kim SC, Seo MY, Lee JY. et al Advanced chronic kidney disease: a strong risk factor for Clostridium difficile infection. Korean J Intern Med (Korean Assoc Intern Med) 2016; 31 (01) 125-133
    PubMedGoogle Scholar
  • 18 Cho SM, Lee JJ, Yoon HJ. Clinical risk factors for Clostridium difficile-associated diseases. Braz J Infect Dis 2012; 16 (03) 256-261
    CrossrefPubMedGoogle Scholar
  • 19 Karaaslan A, Soysal A, Yakut N. et al Hospital acquired Clostridium difficile infection in pediatric wards: a retrospective case-control study. Springerplus 2016; 5 (01) 1329
    CrossrefPubMedGoogle Scholar
  • 20 Selvey LA, Slimings C, Joske DJL, Riley TV. Clostridium difficile infections amongst patients with haematological malignancies: a data linkage study. PLoS One 2016; 11 (06) e0157839
    CrossrefPubMedGoogle Scholar
  • 21 Lv Z, Peng GL, Su JR. Factors associated with Clostridium difficile diarrhea in a hospital in Beijing, China. Braz J Med Biol Res 2014; 47 (12) 1085-1090
    CrossrefPubMedGoogle Scholar
  • 22 Alzouby S, Baig K, Alrabiah F, Shibl A, Al-Nakhli D, Senok AC. Clostridioides difficile infection: Incidence and risk factors in a tertiary care facility in Riyadh, Saudi Arabia. J Infect Public Health 2020; 13 (07) 1012-1017
    CrossrefPubMedGoogle Scholar
  • 23 Tleyjeh IM, Bin Abdulhak AA, Riaz M. et al Association between proton pump inhibitor therapy and clostridium difficile infection: a contemporary systematic review and meta-analysis. PLoS One 2012; 7 (12) e50836
    CrossrefPubMedGoogle Scholar
  • 24 Fuereder T, Koni D, Gleiss A. et al Risk factors for Clostridium difficile infection in hemato-oncological patients: a case control study in 144 patients. Sci Rep 2016; 6: 31498
    CrossrefPubMedGoogle Scholar
  • 25 Eliakim-Raz N, Fishman G, Yahav D. et al Predicting Clostridium difficile infection in diabetic patients and the effect of metformin therapy: a retrospective, case-control study. Eur J Clin Microbiol Infect Dis 2015; 34 (06) 1201-1205
    CrossrefPubMedGoogle Scholar
  • 26 Lall S, Nataraj G, Mehta P. Estimation of prevalence and risk factors for Clostridium difficile infection: a neglected pathogen in a tertiary care setting in India. Int. J. Med. Res. 2017; 5: 298-309
    Google Scholar
  • 27 Alonso CD, Kamboj M. Clostridium difficile infection (CDI) in solid organ and hematopoietic stem cell transplant recipients. Curr Infect Dis Rep 2014; 16 (08) 414
    CrossrefPubMedGoogle Scholar
  • 28 Ingle M, Deshmukh A, Desai D. et al Clostridium difficile as a cause of acute diarrhea: a prospective study in a tertiary care center. Indian J Gastroenterol 2013; 32 (03) 179-183
    CrossrefPubMedGoogle Scholar
  • 29 Khanafer N, Vanhems P, Barbut F. et al CDI01 Study group, Teams of. Factors associated with Clostridium difficile infection: a nested case-control study in a three year prospective cohort. Anaerobe 2017; 44: 117-123
    CrossrefPubMedGoogle Scholar