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C. Difficile Disease Shows Sharp Increase 4-30-08
A new and more severe strain of Clostridium difficile may be playing a role
in a skyrocketing rate of hospitalization for C. difficile-associated disease.
That's the conclusion of a CDC researcher who is tracking the number of hospital
discharges in which C. difficile-associated disease is either a primary or
secondary diagnosis -- a number that more than doubled from 2001 through 2005.
Part of the increase is the result of better detection, according to Michael
Jhung, M.D., of the CDC, but he added it's likely that the NAP1/027 strain of
the disease is a contributing factor.
"We think more people are getting infected and being hospitalized due to these
[NAP1/027] infections," he said.
The NAP1/027 strain has been linked to several deadly outbreaks of disease in
Canada, the U.S., Britain, and The Netherlands and is regarded as more toxic
than other strains (See: New C. Difficile Strain More Toxic).
With Anne Elixhauser, Ph.D., of the Agency for Healthcare Research and Quality,
Dr. Jhung analyzed data from the AHRQ's Healthcare Cost And Utilization Project.
The analysis showed that the rate of hospitalization for C. difficile-associated
disease went from 148,900 in 2001 to 301,200 in 2005 -- a 2.02-fold increase,
the researchers wrote in an AHRQ statistical brief.
The increasing rate contrasts sharply with the preceding eight years, during
which a 74% increase brought the numbers from 85,700 a year to 148,900, they
said.
The rates are increasing "quite dramatically," Dr. Jhung said, and although
hospital discharge data can't pin down a culprit, the NAP1/027 strain seems a
likely candidate for at least some of the increase.
The researchers also calculated the rate of C. difficile-associated disease per
10,000 hospital discharges and found a similar picture -- the rate from 1991
through 2001 was 60%, while from 2001 through 2005 it was 92%.
"The recent sharp rise in C. difficile-associated disease was not attributable
solely to an increase in the number of hospital discharges," they said.
Dr. Jhung cautioned that the number of hospital discharges is not quite the same
as the number of people affected, since a single person hospitalized and
discharged several times would count as separate discharges.
The AHQR data also showed:
* Over the 12-year period, there were 2,037,900 hospital discharges with C.
difficile-associated disease.
* In 2005, about one-quarter of C. difficile-associated disease cases had C.
difficile-associated disease as a principal diagnosis.
* The average age of C. difficile-associated disease patients was 68.3 years,
with about two-thirds older than 65.
* Overall, 58.5% of those diagnosed with C. difficile-associated disease were
female.
* More than 60% of cases with C. difficile-associated disease entered the
hospital through the emergency room.
* Patients with C. difficile-associated disease stayed in the hospital 12.9 days
on average and 9.5% died during their stay. Patients with a secondary diagnosis
of C. difficile-associated disease stayed longer (14.8 days on average) and more
died (11.3%).
* Among all discharges with a diagnosis of C. difficile-associated disease,
there were 28,600 deaths in 2005, while among those with a principal diagnosis
of C. difficile-associated disease, 3,100 died.
* Less than one half of 1% of all C. difficile-associated disease patients
received subtotal colostomy treatment for bowel perforation and peritonitis
resulting from fulminant disease. This accounted for about 1,100 patients by
2005.
* The northeast had the highest rates followed by the midwest, the south, and
the west.
The increase is alarming, Dr. Jhung said, and "we hope it's not going to
continue." He said the CDC is monitoring C. difficile-associated disease as a
priority and is encouraging preventive measures.
In particular, he said, the CDC is urging the "judicious" use of antibiotics,
strict adherence to infection control measures such as hand hygiene, and early
detection and treatment.
Comment:
This article shows a the main cause of this infection is usage if Prilosec.
MONTREAL, Dec. 20 - Commonly used heartburn drugs appear to be contributing
to the rapid increase of community-acquired Clostridium difficile diarrheal
infection.
Suppression of gastric acid with proton-pump inhibitors drugs like Prilosec (omeprazole)
or Nexium (esomeprazole) is associated with a two- to threefold increase in the
risk of community acquired Clostridium difficile, according to researchers here.
The finding supports the hypothesis that the mechanism of increased C. difficile
risk is related to the degree of gastric acid suppression, Sandra Dial, M.D.,
M.Sc., of McGill University and colleagues reported in the Dec. 21 issue of the
Journal of the American Medical Association.
Analysis of medical records from patients treated by general practitioners in
England found that the incidence of C. difficile diagnosed by GPs jumped from
less than 1 case per 100,000 population in 1994 to 22 cases per 100,000 in 2004.
That increase is mainly due to the increased use of gastric acid suppressors,
wrote Dr. Dial and colleagues.
The adjusted relative risk for current proton pump inhibitor exposure was 2.9
and the adjusted relative risk for current H2 -receptor agonist exposure was
2.0. Current exposure to NSAIDs, but not aspirin, was also associated with a
slight increase in risk of C. difficile. Proton pump inhibitors more effectively
suppress gastric acid than H2 -receptor agonists.
Decreased gastric acidity, they wrote, is "a known risk factor for other
infectious diarrheal illnesses such as travelers' diarrhea, salmonellosis, and
cholera."
The concluded, "Acid-suppressive agents are among the most frequently prescribed
medications in the United Kingdom and North America, and it is in this context
that the contribution of these agents by potentially increasing the pool of
susceptible hosts to the increasing rates of [C. difficile-associated disease]
need to be considered and more completely characterized."
C. Difficile is usually considered a nosocomial infection, but in this analysis
the researchers identified 1,233 cases among patients who had not been
hospitalized in the year prior to diagnosis. Those 1,233 cases account for 74%
of the 1627 cases of C. difficile identified in the General Practice Research
Database.
The researchers compared cases with age-matched controls. Four hundred of the
1,233 cases were diagnosed by clinical symptoms and 833 were identified by
positive toxin assay.
The mean age of patients with community-acquired C. difficile was 71 and most of
the cases were women. Other factors associated with C. difficile were history of
renal failure, inflammatory bowel disease, malignancy, and methicillin-resistant
Staphylococcus aureus-positive.