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Byun, Han, Ahn, Cho, Kim, Eun, Jeon, Sohn, and Kang: Clinical Characteristics and Changing Epidemiology of Clostridium difficile-Associated Disease (CDAD)
Original Article

Korean J Gastroenterol 2009;54(1):13-19.

Published online: 21 February 2009

DOI: https://doi.org/10.4166/kjg.2009.54.1.13

Clinical Characteristics and Changing Epidemiology of Clostridium difficile-Associated Disease (CDAD)

Tae Jun Byun, M.D., Dong Soo Han, M.D., Sang Bong Ahn, M.D., Hyun Seok Cho, M.D., Tae Yeob Kim, M.D., Chang Soo Eun, M.D., Yong Cheol Jeon, M.D., Joo Hyun Sohn, M.D., Jung Oak Kang, M.D.∗

Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea

∗Department of Laboratory Medicine, Hanyang University College of Medicine, Guri, Korea

Correspondence to: Dong Soo Han, M.D. Department of Internal Medicine, Guri Hospital, Hanyang University College of Medicine, 249-1, Gyomun-dong, Guri 471-701, Korea Tel: +82-31-560-2226, Fax: +82-31-555-2998 E-mail: hands@hanyang.ac.kr

Received 6 August 2008       Accepted 27 September 2008

Copyright © 2009 The Korean Journal of Gastroenterology

Abstract

Background/Aims

The spectrum of Clostridium difficile-associated disease (CDAD) ranges from mild diarrhea to life-threatening colitis. Recent studies reported an increase in incidence and severity of CDAD and the presence of severe community-acquired CDAD (CA-CDAD). The aims of this study were to investigate the incidence of CA-CDAD and non-antibiotics-associated CDAD, and to compare the clinical characteristics between hospital-acquired (HA) and CA-CDAD.

Methods

The medical records of 86 patients who were diagnosed as CDAD in Hanyang University Guri Hospital between January 2005 and October 2007 were retrospectively reviewed.

Results

Of the 86 patients (mean age 64 years), 53 patients were women. The most frequently prescribed antibiotics were cephalosporins (67.4%), followed by aminoglycosides (38.4%) and quinolones (14%). Of the 86 patients, the average duration of treatment and recovery time of symptoms were 11.5 days and 4.6 days, respectively. Seven percent of patients experienced relapse treatment. The overall incidence rate of CA-CDAD and non-antibiotics-associated CDAD were 10.5% and 22.1%, respectively. CA-CDAD group had lower rate of anti-microbial exposure whilst showing higher rate of complications compared to HA-CDAD group. Three patients in the CA-CDAD progressed towards a severe complicated clinical course, including septic shock.

Conclusions

The incidence rate of CA-CDAD and non-antibiotics-associated CDAD were 10.5% and 22.1%, respectively. CA-CDAD tends to have a higher complication rate compared to HA-CDAD. Community clinicians needs to maintain a high level of suspicion for CDAD, whilst coping with the ever evolving epidemiologic change.

Keywords: Clostridium difficile, Clostridium difficile-associated disease (CDAD), Community-acquired C. difficile-associated disease (CA-CDAD)

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Table 1.
Case Definition for Community-acquired CDAD
Confirmed case of CA-CDAD
Any adult with each of the following
Diarrhea
No serious, chronic underlying illness (e.g., severe chronic liver or kidney disease)
No overnight stay in a healthcare facility for ≥3 months before diarrhea onset
Evidence of CDAD by any of the following
Positive assay for C. difficile toxin
Colonic histopathology characteristics of C. difficile infection
Pseudomembranous colitis observed on lower gastrointestinal endoscopy
Positive stool culture for C. difficile
CDAD, Clostridium difficile-associated disease. Adapted from reference 13.
Table 2.
Baseline Characteristics of Patients with CDAD
Characteristics N No. of patients (n=86)
Age, median (range) 64 (20-94)
Female sex 53 (61.6%)
Comorbid conditions
Cancer 19 (22.1%)
Neurologic disorders 15 (17.4%)
Diabetes mellitus 7 (8.1%)
Liver cirrhosis 6 (7%)
Chronic renal failure 6 (7%)
Antimicrobial exposures
Any cephalosporins 58 (67.4%)
Any aminoglycosides 33 (38.4%)
Any quinolones 12 (14%)
Antibiotics non-exposure 19 (22.1%)
Duration of antimicrobial exposures 16.1 days
Grading of diarrhea, grade II (moderate 47.7%
Clinical symptoms (e.g., abdominal pain, fever, vomiting) 67.4%
Length of stay before diagnosis 22.8 days
Proton pump inhibitors use 19 (22.1%)
Initial treatment regimen (metronidazole) 95.8%
Average duration of treatment 11.5 days
Average recovery time (diarrhea) 4.6 days
Relapse 6 (7%)
Severe complication (e.g., sepsis, megacolon, etc) 6 (7%)

CDAD, Clostridium difficile-associated disease.

Table 3.
Incidence of CA-CDAD and Non-antibiotics-associated CDAD
CA-CDAD HA-CDAD Total
Antibiotics Exposure 1 66 67
Antibiotics Non-exposure 8 11 19
Total 9 77 86

CA-CDAD 9/86 (10.5%), antimicrobial non-exposure 19/86(22.1%). CA-CDAD, community-acquired Clostridium difficile-associated disease; HA-CDAD, hospital-acquired Clostridium difficile-associated disease.

Table 4.
Comparison of Clinical Characteristics between CA-CDAD and HA-CDAD
CA-CDAD (n=9) HA-CDAD (n=77) p-value
Demographic
Age 59.7±13.4 64.6±15.1 0.330
Female sex 8 (89%) 45 (58%) 0.076
Diagnosis
Positive toxin assay 5 (55%) 29 (41%) 0.400
Positive culture 2 (22%) 20 (28%) 0.707
Positive endoscopy & biopsy 5 (62%) 50 (87%) 0.064
Clinical
Symptom 6 (67%) 49 (64%) 0.858
(e.g., abdominal pain,
fever, vomiting)
Antibiotics exposure 1 (11%) 66 (85%) 0.000∗
PPI use 1 (11%) 18 (23%) 0.401
ICU care 1 (11%) 18 (23%) 0.542
Complication 3 (33%) 3 (4%) 0.001∗
Ileus 3 (33%) 31 (40%) 0.688
Fever (o C) 37.3±0.92 37.8±0.73 0.409
Systolic BP (mmHg )118.3±21.2 120.3±13.0 0.783
Laboratory finding
WBC (/mm3) 12,533±8,889 12,737.8±7,037 7 0.948
Albumin (g/dL) 3.2±0.5 2.9±0.5 0.153
Creatinine (mg/dL) 0.8±0.2 1.3±1.8 0.021∗
Treatment related
Treatment period 10.5±2.5 11.6±5.0 0.467
(days)
Recovery period (days) 3.6±1.1 4.7±2.4 0.256
Treatment failure 1 (11%) 4 (6%) 0.148

CA-CDAD, community-acquired Clostridium difficile-associated disease; HA-CDAD, hospital-acquired Clostridium difficile-associated disease; PPI, proton pump inhibitor; ICU, intensive care unit; BP, blood pressure; WBC, white blood cell.

∗ p-value＜0.05 mean± SD.

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