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Epidemiology of Clostridium difficile infection in Portugal: Experience at a tertiary care hospital

  • Sara Sintra
    Correspondence
    Corresponding author at: Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra 3000-075, Portugal.
    Affiliations
    Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

    Internal Medicine Clinic, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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  • Filipe Taveira
    Affiliations
    Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

    Internal Medicine Clinic, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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  • Catarina Canha
    Affiliations
    Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

    Internal Medicine Clinic, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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  • Armando Carvalho
    Affiliations
    Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

    Internal Medicine Clinic, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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  • Adélia Simão
    Affiliations
    Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

    Internal Medicine Clinic, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Published:October 18, 2018DOI:https://doi.org/10.1016/j.ejim.2018.10.009

      Highlights

      • Clostridium difficile infection incidence achieved a dramatic increase in 2009/2010 in Coimbra, Portugal.
      • Peak incidence coincided with the introduction of alcohol-based hand products.
      • Increase in carbapenem and quinolone prescription had also a potential influence.
      • A possible outbreak of an epidemic strain cannot be excluded.

      Abstract

      Background

      Clostridium difficile is the main cause of healthcare-associated diarrhoea. Its incidence, severity and relapse rates increased over the past two decades.

      Aim

      To study epidemiologic characteristics and treatment of Clostridium difficile infection (CDI) and compare with a previous cohort from the same hospital.

      Method

      Retrospective analysis of clinical records of CDI diagnosed from 2010 to 2015 and comparison with data from 2004 to 2009.

      Results

      259 cases were diagnosed, compared to 83 in 2004–2009. There was no difference in mean annual incidence (8.66 versus 7.11 per 1000 patients; p = .116), but a dramatic increase was observed in 2009/2010 (peak incidence: 21.63 cases per 1000 admissions). Females were more affected (61.4% versus 69.9%; p = .177). Median age was 80 and 83 (p = .097). We observed an increase in median number of antibiotics previously used (2 versus 3; p = .147) and in community-associated CDI (6% versus 19.7%; p = .003). There was a continued increase in the use of carbapenems and quinolones until 2010 and a high percentage of refractory cases in 2010. Female gender (p = .043), long-term care facility (LTCF) residency (p = .022) and a higher number of previous antibiotics (median of 3; p = .025) were independent predictors for refractory and recurrent CDI.

      Conclusions

      CDI incidence achieved a peak in 2009/2010 coinciding with the introduction of alcohol-based hand products, increase in quinolone and carbapenem prescription and a possible outbreak of an epidemic strain. Female gender, LTCF residency and exposure to three or more antibiotics are risk factors for refractory and recurrent CDI. We emphasize the need to restrict use of large spectrum antibiotics.

      Keywords

      Abbreviations:

      CDI (Clostridium difficile infection), CA-CDI (community-associated CDI), HA-CDI (healthcare-associated CDI), OR (odds ratio), LTCF (long-term care facilities)
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