Clostridium difficile associated diarrhea at a tertiary care center in lebanon

Background: Since 2001, the prevalence and severity of C. difficile infection have increased significantly, and C. difficile is now considered to be one of the most important causes of health care-associated infections. This poses a need for infection control programs to re-evaluate their policies and implement more strict prevention measures. The most effective way described in the literature to prevent horizontal spread of C. difficile has been a combination of hand hygiene with soap and water and implementation of contact isolation for symptomatic patients.

Unfortunately there is lack of a standardized surveillance system and data about the epidemiology of C. difficile infections in Lebanon. As such it is vital to study the epidemiology of infections caused by this organism in Lebanon in order to reduce the burden of the disease.

Objective: Study the epidemiology of CDAD at AUBMC

Methods: We undertook a retrospective review of all cases that tested positive for C. difficile toxin A or B at the American University of Beirut Medical Center (AUBMC) from January 2007 till March 2009. We abstracted data from individual patient medical records and from electronic laboratory data. Patients below 18 years of age were excluded.

Results: Total of 87 cases were included in the analysis. Patients had a mean age of 60.3 years (range 18-93 years), majority being females (44/87 = 51%) with a mean Charlson comorbidity score of 5.2 (range 0-14). Most infections (78.2%) were hospital acquired. Records reveal that the infection control team was informed about only 47 CDAD cases. Based on the recommendations of the ICPP team, 15 patients were placed in single rooms, 8 in double bedrooms and the remaining patients had no record of intervention by the team.
Predisposing factors: 74.7% of patients had received antibiotics within 24 hours of developing CDAD and 80.5% had received antibiotics for more than 48 hours within 30 days preceding the infection. Cephalosporins were the most commonly incriminated antibiotics. 72.4% of patients had been admitted to the hospital within the preceding 30 days.
Treatment: 92% of patients were treated with oral metronidazole and 4.6% required combination therapy with vancomycin. The mean duration of therapy was 10 days.
Complications: 9 patients developed toxic megacolon, 4 developed sepsis, 19 had persistence of the symptoms, 10 had recurrence of the infection within 8 weeks, and 8 patients required ICU admission. There were 11 deaths, one of which was thought to be attributable to CDAD.

Conclusions: This study suggests that the majority of CDAD cases were hospital acquired. The notification system by the treating team to the ICPP needs substantial improvement. Interventions by the ICPP should also be more prominent. Predisposing factors, complications, and outcome of CDAD were comparable to results noted in the literature. Further studies are needed to assess the efficacy of interventions aimed at decreasing the burden of CDAD.