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A Large Outbreak of Clostridium difficile–Associated Disease with an Unexpected Proportion of Deaths and Colectomies at a Teaching Hospital Following Increased Fluoroquinolone Use

Published online by Cambridge University Press:  21 June 2016

Carlene A. Muto
Affiliation:
Division of Hospital Epidemiology and Infection Control, University of Pittsburgh Medical Center, Presbyterian Campus, Pittsburgh, Pennsylvania Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine, and Graduate School of Public Health, Pittsburgh, Pennsylvania
Marian Pokrywka
Affiliation:
Division of Hospital Epidemiology and Infection Control, University of Pittsburgh Medical Center, Presbyterian Campus, Pittsburgh, Pennsylvania
Kathleen Shutt
Affiliation:
Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine, and Graduate School of Public Health, Pittsburgh, Pennsylvania
Aaron B. Mendelsohn
Affiliation:
Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania
Kathy Nouri
Affiliation:
Division of Hospital Epidemiology and Infection Control, University of Pittsburgh Medical Center, Presbyterian Campus, Pittsburgh, Pennsylvania
Kathy Posey
Affiliation:
Division of Hospital Epidemiology and Infection Control, University of Pittsburgh Medical Center, Presbyterian Campus, Pittsburgh, Pennsylvania
Terri Roberts
Affiliation:
Division of Hospital Epidemiology and Infection Control, University of Pittsburgh Medical Center, Presbyterian Campus, Pittsburgh, Pennsylvania
Karen Croyle
Affiliation:
Division of Hospital Epidemiology and Infection Control, University of Pittsburgh Medical Center, Presbyterian Campus, Pittsburgh, Pennsylvania
Sharon Krystoflak
Affiliation:
Division of Hospital Epidemiology and Infection Control, University of Pittsburgh Medical Center, Presbyterian Campus, Pittsburgh, Pennsylvania
Sujata Patel-Brown
Affiliation:
Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine, and Graduate School of Public Health, Pittsburgh, Pennsylvania
A. William Pasculle
Affiliation:
Division of Microbiology, University of Pittsburgh Medical Center, Presbyterian Campus, Pittsburgh, Pennsylvania Department of Pathology, Pittsburgh, Pennsylvania
David L. Paterson
Affiliation:
Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine, and Graduate School of Public Health, Pittsburgh, Pennsylvania
Melissa Saul
Affiliation:
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Lee H. Harrison
Affiliation:
Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine, and Graduate School of Public Health, Pittsburgh, Pennsylvania
Corresponding
E-mail address:

Abstract

Background and Objective:

Fluoroquinolones have not been frequently implicated as a cause of Clostridium difficile outbreaks. Nosocomial C. difficile infections increased from 2.7 to 6.8 cases per 1,000 discharges (P < .001). During the first 2 years of the outbreak, there were 253 nosocomial C. difficile infections; of these, 26 resulted in colectomy and 18 resulted in death. We conducted an investigation of a large C. difficile outbreak in our hospital to identify risk factors and characterize the outbreak.

Methods:

A retrospective case-control study of case-patients with C. difficile infection from January 2000 through April 2001 and control-patients matched by date of hospital admission, type of medical service, and length of stay; an analysis of inpatient antibiotic use; and antibiotic susceptibility testing and molecular subtyping of isolates were performed.

Results:

On logistic regression analysis, clindamycin (odds ratio [OR], 4.8; 95% confidence interval [CI95], 1.9-12.0), ceftriaxone (OR, 5.4; CI95, 1.8-15.8), and levofloxacin (OR, 2.0; CI95, 1.2-3.3) were independently associated with infection. The etiologic fractions for these three agents were 10.0%, 6.7%, and 30.8%, respectively. Fluoroquinolone use increased before the onset of the outbreak (P < .001); 59% of case-patients and 41% of control-patients had received this antibiotic class. The outbreak was polyclonal, although 52% of isolates belonged to two highly related molecular subtypes.

Conclusions:

Exposure to levofloxacin was an independent risk factor for C. difficile-associated diarrhea and appeared to contribute substantially to the outbreak. Restricted use of levofloxacin and the other implicated antibiotics may be required to control the outbreak.

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2005

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