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      Recent changes in Clostridium difficile infection Translated title: Recentes mudanças da infecção por Clostridium difficile

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          Abstract

          Clostridium difficile is the main cause of nosocomial diarrhea. Diarrhea associated with C. difficile has increased incidence, morbidity, and mortality in the last few years. The major related risk factors include use of antibiotics, elderly patients and prolonged hospital stay. Many patients receive combinations of antibiotics or multiple antibiotics, which represents the main risk to develop diarrhea associated to C. difficile or its recurrence. Therefore, interventions to improve antibiotic prescribing, as well as compliance with infection control measures can reduce hospital-acquired C. difficile infections. This review addresses the epidemiological changes in C. difficile disease and its treatment.

          Translated abstract

          Clostridium difficile é a principal causa de diarreia hospitalar. A diarreia por C. difficile aumentou sua incidência e sua morbiletalidade nos últimos anos. Os principais fatores de risco relacionados são uso de antibióticos, idosos e permanência hospitalar prolongada. Muitos pacientes recebem combinação de antibióticos ou múltiplos antibióticos, constituindo-se, assim, o principal fator de risco para o desenvolvimento de infecção ou de recorrência de diarreia associada ao C. difficile. Por isso, intervenções que otimizem a prescrição de antibióticos associado à aderência de medidas de controle de infecção podem reduzir aquisição dessa infecção. Assim, esta revisão aborda a mudança da epidemiologia da infecção por C. difficile e seu tratamento.

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          Most cited references29

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          A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality.

          In March 2003, several hospitals in Quebec, Canada, noted a marked increase in the incidence of Clostridium difficile-associated diarrhea. In 2004 we conducted a prospective study at 12 Quebec hospitals to determine the incidence of nosocomial C. difficile-associated diarrhea and its complications and a case-control study to identify risk factors for the disease. Isolates of C. difficile were typed by pulsed-field gel electrophoresis and analyzed for binary toxin genes and partial deletions in the toxin A and B repressor gene tcdC. Antimicrobial susceptibility was evaluated in a subgroup of isolates. A total of 1703 patients with 1719 episodes of nosocomial C. difficile-associated diarrhea were identified. The incidence was 22.5 per 1000 admissions. The 30-day attributable mortality rate was 6.9 percent. Case patients were more likely than matched controls to have received fluoroquinolones (odds ratio, 3.9; 95 percent confidence interval, 2.3 to 6.6) or cephalosporins (odds ratio, 3.8; 95 percent confidence interval, 2.2 to 6.6). A predominant strain, resistant to fluoroquinolones, was found in 129 of 157 isolates (82.2 percent), and the binary toxin genes and partial deletions in the tcdC gene were present in 132 isolates (84.1 percent). A strain of C. difficile that was resistant to fluoroquinolones and had binary toxin and a partial deletion of the tcdC gene was responsible for this outbreak of C. difficile-associated diarrhea. Exposure to fluoroquinolones or cephalosporins was a risk factor. Copyright 2005 Massachusetts Medical Society.
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            What have we learned about antimicrobial use and the risks for Clostridium difficile-associated diarrhoea?

            J Blondeau (2009)
            Clostridium difficile is recognized as a major cause of antibiotic-associated diarrhoea and colitis. Antimicrobial agents have been repeatedly recognized as a causative risk for C. difficile-associated diarrhoea (CDAD) and more recently fluoroquinolones have been particularly implicated. Unfortunately, not all reports of antimicrobial associations with CDAD have excluded variables other than antimicrobial use. Prevention of CDAD usually involves infection control interventions and antimicrobial restriction policies may not be fully substantiated by currently available data; however, antimicrobial drug restriction seems prudent in outbreak situations.
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              Epidemiology and outcomes of clostridium difficile-associated disease among patients on prolonged acute mechanical ventilation.

              Patients receiving prolonged acute mechanical ventilation (PAMV), although comprising a third of all mechanical ventilation (MV) patients, consume two-thirds of all the resources allocated to MV, and their numbers are projected to double by 2020. By virtue of their prolonged hospital length of stay (median LOS, 17 days), they are subject to such nosocomial infections as Clostridium difficile-associated disease (CDAD), the incidence and age-adjusted case fatality rate of which doubled between 2000 and 2005. We examined the rates and outcomes of CDAD among adult PAMV patients. We analyzed 2005 data from the Health Care Utilization Project/Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. PAMV and CDAD were identified using the International Classification of Diseases, ninth revision, clinical modification codes 96.72 and 008.45, respectively. Among 64,910 adult PAMV patients who were discharged in 2005, 3,468 patients (5.34%) had a concurrent diagnosis of CDAD (PAMV patients who were discharged with concomitant diagnosis of CDAD [CDAD+]). CDAD+ patients who were discharged were older (mean [+/- SD] age, 66.7 +/- 15.9 vs 63.7 +/- 16.9 years, respectively; p < 0.001) and were more likely to have been admitted to the hospital from a long-term care facility (5.7% vs 2.9%, respectively; p < 0.001) than PAMV patients who were discharged without CDAD (CDAD-). Although crude hospital mortality rates did not differ among PAMV patients who were discharged from the hospital by CDAD status (CDAD+, 32.6%; CDAD-, 33.0%; p = 0.598), both unadjusted calculations and propensity-score adjustment showed a substantial increase in LOS (6.1 days; 95% confidence interval [CI], 4.9 to 7.4) and total costs ($10,355; 95% CI, $7,540 to $13,170) among CDAD+ patients. PAMV patients have an order of magnitude higher risk of having CDAD than other hospitalized patients. Concurrent CDAD infection is associated with increased hospital LOS and costs. The PAMV population is an attractive target for aggressive measures aimed at CDAD prevention.
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                Author and article information

                Contributors
                Role: ND
                Journal
                eins
                Einstein (São Paulo)
                Einstein (São Paulo)
                Instituto Israelita de Ensino e Pesquisa Albert Einstein (São Paulo )
                2317-6385
                March 2012
                : 10
                : 1
                : 105-109
                Affiliations
                [1 ] Hospital Israelita Albert Einstein Brazil
                Article
                S1679-45082012000100023
                10.1590/S1679-45082012000100023
                f0ac1c19-bfa6-4147-9a31-6e7990c5f1cc

                http://creativecommons.org/licenses/by/4.0/

                History
                Product

                SciELO Brazil

                Self URI (journal page): http://www.scielo.br/scielo.php?script=sci_serial&pid=1679-4508&lng=en
                Categories
                MEDICINE, GENERAL & INTERNAL

                Internal medicine
                Clostridium difficile,Diarrhea,Anti-bacterial agents,Risk factors,Diarreia,Antibacterianos,Fatores de risco

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