Skip to main content Accessibility help
×
Home

Multihospital Outbreak of Clostridium difficile Ribotype 027 Infection: Epidemiology and Analysis of Control Measures

  • Mamoon A. Aldeyab (a1), Michael J. Devine (a2), Peter Flanagan (a3), Michael Mannion (a3), Avril Craig (a2), Michael G. Scott (a3), Stephan Harbarth (a4), Nathalie Vernaz (a5), Elizabeth Davies (a3), Jon S. Brazier (a6), Brian Smyth (a7), James C. McElnay (a1), Brendan F. Gilmore (a8), Geraldine Conlon (a3), Fidelma A. Magee (a3), Feras W. Darwish Elhajji (a1), Shaunagh Small (a3), Collette Edwards (a3), Chris Funston (a3) and Mary P. Kearney (a3)...

Abstract

Objective.

To report a large outbreak of Clostridium difficile infection (CDI; ribotype 027) between June 2007 and August 2008, describe infection control measures, and evaluate the impact of restricting the use of fluoroquinolones in controlling the outbreak.

Design.

Outbreak investigation in 3 acute care hospitals of the Northern Health and Social Care Trust in Northern Ireland.

Interventions.

Implementation of a series of CDI control measures that targeted high-risk antibiotic agents (ie, restriction of fluoroquinolones), infection control practices, and environmental hygiene.

Results.

A total of 318 cases of CDI were identified during the outbreak, which was the result of the interaction between C. difficile ribotype 027 being introduced into the affected hospitals for the first time and other predisposing risk factors (ranging from host factors to suboptimal compliance with antibiotic guidelines and infection control policies). The 30-day all-cause mortality rate was 24.5%; however, CDI was the attributable cause of death for only 2.5% of the infected patients. Time series analysis showed that restricting the use of fluoroquinolones was associated with a significant reduction in the incidence of CDI (coefficient, —0.054; lag time, 4 months; P = .003).

Conclusion.

These findings provide additional evidence to support the value of antimicrobial stewardship as an essential element of multifaceted interventions to control CDI outbreaks. The present CDI outbreak was ended following the implementation of an action plan improving communication, antibiotic stewardship, infection control practices, environmental hygiene, and surveillance.

Copyright

Corresponding author

Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, United Kingdom (maldeyab02@qub.ac.uk)

References

Hide All
1.Thompson, I. Clostridium difficile-associated disease: update and focus on non-antibiotic strategies. Age Ageing 2008;37:1418.
2.Kuijper, EJ, Barbut, F, Brazier, JS, et al.Update of Clostridium difficile infection due to PCR ribotype 027 in Europe, 2008. Eurosurveillance 2008;13(31)pii: 18942.
3.McFarland, LV. Update on the changing epidemiology of Clostridium difficile-associated disease. Nat Clin Pract Gastroenterol Hepatol 2008;5:4048.
4.Labbé, A-C, Poirier, L, MacCannell, D, et al.Clostridium difficile infections in a Canadian tertiary care hospital before and during a regional epidemic associated with the BI/NAP1/027 strain. Antimicrob Agents Chemother 2008;52:31803187.
5.Warny, M, Pepin, J, Fang, A, et al.Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 2005;366:10791084.
6.Debast, SB, Vaessen, N, Choudry, A, Wiegers-Ligtvoet, EA, van den Berg, RJ, Kuijper, EJ. Successful combat of an outbreak due to Clostridium difficile PCR ribotype 027 and recognition of specific risk factors. Clin Microbiol Infect 2009;15:427434.
7.MacCannell, DR, Louie, TJ, Gregson, DB, et al.Molecular analysis of Clostridium difficile PCR ribotype 027 isolates from eastern and western Canada. J Clin Microbiol 2006;44:21472152.
8.Long, S, Fenelon, L, Fitzgerald, S, et al.First isolation and report of clusters of Clostridium difficile PCR 027 cases in Ireland. Eurosurveillance 2007;12(17):pii = 3183.
9.Aldeyab, MA, Monnet, DL, López-Lozano, JM, et al.Modelling the impact of antibiotic use and infection control practices on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus: a time-series analysis. J Antimicrob Chemother 2008;62:593600.
10.Harris, AD, Shardell, M, El-Kamary, SS, Furano, JP, Miller, RR, Perencevich, EN. Statistical analysis and application of quasi experiments to antimicrobial resistance intervention studies. Clin Infect Dis 2007;45:901907.
11.Aldeyab, MA, Harbarth, S, Vernaz, N, et al.Quasiexperimental study of the effects of antibiotic use, gastric acid-suppressive agents, and infection control practices on the incidence of Clostridium difficile-associated diarrhea in hospitalized patients. Antimicrob Agents Chemother 2009;53:20822088.
12.O'Neill, GL, Ogunsola, FT, Brazier, JS, Duerden, BI. Modification of a PCR ribotyping method for application as a routine typing scheme for Clostridium difficile. Anaerobe 1996;2:205209.
13.Stubbs, SLJ, Brazier, JS, O'Neill, GL, Duerden, BI. PCR targeted to the 16S-23S rRNA gene intergenic spacer region of Clostridium difficile and construction of a library consisting of 116 different PCR ribotypes. J Clin Microbiol 1999;37:461463.
14.Lewis, SJ, Heaton, KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997;32:920924.
15.McDonald, LC, Coignard, B, Dubberke, E, et al., and the Ad Hoc Clostridium difficile Surveillance Working Group. Recommendations for surveillance of Clostridium difficile-associated disease. Infect Control Hosp Epidemiol 2007;28:140145.
16.WHO Collaborating Center for Drug Statistics Methodology. Guidelines for ATC classifications and DDD assignment. Oslo: WHO Collaborating Center; 2002.
17.Department of Health (United Kingdom). 2007. High Impact Intervention No 7: care bundle to reduce the risk from Clostridium difficile. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_078126.pdf. Accessed January 30, 2010.
18.Department of Health Social Services and Public Safety (United Kingdom). Guidance on Death, Stillbirth and Cremation Certification. http://www.dhsspsni.gov.uk/show_publications?txtid = 32940. Accessed January 30, 2010.
19.Helfenstein, U. Box-Jenkins modelling in medical research. Stat Methods Med Res 1996;5:322.
20.Tobacman, JK. Assessment of comorbidity: a review. Clin Perform Quoi Health Care 1994;2:2332.
21.Stone, SP, Cooper, BS, Kibbler, CC, et al.The ORION statement: guidelines for transparent reporting of outbreak reports and intervention studies of nosocomial infection. Lancet Infect Dis 2007;7:282288.
22.Schwaber, MJ, Simhon, A, Block, C, Rovai, V, Ferderber, N, Shapiro, M. Factors associated with nosocomial diarrhea and Clostridium difficile-associated disease on the adult wards of an urban tertiary care hospital. Eur J Clin Microbiol Infect Dis 2000;19:915.
23.Muto, CA, Pokrywka, M, Shutt, K, et al.A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol 2005;26:273280.
24.Baxter, R, Ray, GT, Fireman, BH. Case-control study of antibiotic use and subsequent Clostridium difficile-associated diarrhea in hospitalized patients. Infect Control Hosp Epidemiol 2008;29:4450.
25.Owens, RC Jr, Donskey, CJ, Gaynes, RP, Loo, VG, Muto, CA. Antimicrobial-associated risk factors for Clostridium difficile infection. Clin Infect Dis 2008;46(suppl 1):S19S31.
26.Akhtar, AJ, Shaheen, M. Increasing incidence of Clostridium difficile-associated diarrhea in African-American and Hispanic patients: association with the use of proton pump inhibitor therapy. J Natl Med Assoc 2007;99:500504.
27.Cadle, RM, Mansouri, MD, Logan, N, Kudva, DR, Musher, DM. Association of proton-pump inhibitors with outcomes in Clostridium difficile colitis. Am J Health Syst Pharm 2007;64:23592363.
28.Dial, S, Delaney, JA, Barkun, AN, Suissa, S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005;294:29892995.
29.Apisarnthanarak, A, Zack, JE, Mayfield, JL, et al.Effectiveness of environmental and infection control programs to reduce transmission of Clostridium difficile. Clin Infect Dis 2004;39:601602.
30.Regulation and Quality Improvement Authority (United Kingdom). Clostridium difficile—RQIA Independent Review. Review of the Outbreak of Clostridium difficile in the Northern Health and Social Care Trust, http://www.dhsspsni.gov.uk/assemblydocumentcdiffl4108.pdf. Accessed July 1, 2010.
31.Aldeyab, MA, Elshibly, SM, McElnay, JC, et al.An evaluation of compliance with an antibiotic policy in surgical wards at a general teaching hospital in Northern Ireland. Infect Control Hosp Epidemiol 2009;30:921922.
32.Kuijper, EJ, Coignard, B, Tüll, P, ESCMID Study Group for Clostridium difficile, EU Member States, European Centre for Disease Prevention and Control. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2006;12(suppl 6):218.
33.Morgan, OW, Rodrigues, B, Elston, T, et al.Clinical severity of Clostridium difficile PCR ribotype 027: a case-case study. PLoS one 2008;3(3):e1812.
34.Loo, VG, Poirier, L, Miller, MA, et al.A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:24422449.
35.Hubert, B, Loo, VG, Bourgault, A-M, et al.A portrait of the geographic dissemination of the Clostridium difficile North American pulsed-field type 1 strain and the epidemiology of C. difficile-associated disease in Quebec. Clin Infect Dis 2007;44:238244.
36.Barbut, F, Gariazzo, B, Bonné, L, et al.Clinical features of Clostridium difficile-associated infections and molecular characterization of strains: results of a retrospective study, 2000-2004. Infect Control Hosp Epidemiol 2007;28:131139.
37.Goorhuis, A, Van der Kooi, T, Vaessen, N, et al.Spread and epidemiology of Clostridium difficile polymerase chain reaction ribotype 027/toxinotype III in The Netherlands. Clin Infect Dis 2007;45:695703.
38.Miller, M, Gravel, D, Mulvey, M, et al.Health care-associated Clostridium diffidi infection in Canada: patient age and infecting strain type are highly predictive of severe outcome and mortality. Clin Infect Dis 2010;50:194201.
39.Kallen, AJ, Thompson, A, Ristaino, P, et al.Complete restriction of fluoroquinolone use to control an outbreak of Clostridium difficile infection at a community hospital. Infect Control Hosp Epidemiol 2009;30:264272.
40.McElnay, JC, Scott, MG, Sidara, JY, Kearney, P. Audit of antibiotic usage in medium-sized general hospital over an 11-year period: the impact of antibiotic policies. Pharm World Sci 1995;17:207213.
41.Al-Eidan, FA, McElnay, JC, Scott, MG, Kearney, MP. Clostridium difficile-associated diarrhoea in hospitalised patients. J Clin Pharm Ther 2000;25:101109.
42.Valiquette, L, Cossette, B, Garant M-P, Diab, H, Pépin, J. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007;45(suppl 2):S112S121.
43.Vonberg, RP, Kuijper, EJ, Wilcox, MH, et al.Infection control measures to limit the spread of Clostridium difficile. Clin Microbiol Infect 2008;14(suppl 5):220.

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed