Clostridium difficile cases are on the rise, according to a study in Archives of Surgery. It seems odd to me that this study would come out now, just a few days after I posted about the same topic. I posted about it because of the finding that the active cultures, that are used in yogurt, appear to reduce the frequency and severity of C. diff. colitis. I like to blog about medical interventions that are extremely inexpensive, yet yield large benefits.
The Archives of Surgery journal article shows that the frequency and severity of Clostridium difficile colitis in hospitalized patients have increased. The severity was measured by case fatality, total mortality rate, and colectomy rate.
Increasing Prevalence and Severity of Clostridium difficile Colitis in Hospitalized Patients in the United States
Rocco Ricciardi, MD, MPH; David A. Rothenberger, MD; Robert D. Madoff, MD; Nancy N. Baxter, MD, PhD
Arch Surg. 2007;142:624-631
Objective To evaluate changes in the epidemiological features of Clostridium difficileC difficile is a common cause of nosocomial diarrhea that has been shown to be increasing in virulence in Canada and across Europe).
Design Cohort analysis of all patients with C difficile colitis in the Nationwide Inpatient Sample.
Setting Population-based data from the Nationwide Inpatient Sample, a 20% stratified random sample of US hospital discharge abstracts from January 1, 1993, through December 31, 2003.
Patients Using standard International Classification of Diseases, Ninth RevisionC difficile colitis. We controlled for comorbid conditions by calculating the Deyo modification of the Charlson score. To determine the relationship of year of diagnosis on main outcome measures, we constructed multivariate models.
Main Outcome Measures The prevalence, case fatality, total mortality rate, and colectomy rate of C difficile colitis.
Results We found that the prevalence, case fatality, total mortality rate, and colectomy rate of C difficile colitis increased from 1993 through 2003. In our regression analysis, the year of diagnosis predicted an increase in prevalence, case fatality, total mortality rate, and colectomy rate after adjusting for potential confounders.
Conclusions The prevalence, case fatality, total mortality rate, and colectomy rate of C difficileC difficile colitis in hospitalized patients in the United States ( (ICD-9) diagnostic codes, we identified patients with colitis significantly increased from 1993 to 2003. These findings provide compelling evidence of the changing epidemiological features of colitis.
It turns out that one to three percent of healthy people walk around with C. diff living inside. They have no problems with it. About 20% of people treated with antibiotics get it. Some, but not all, develop colitis. Initially, this was associated with the antibiotic, clindamycin. Later it was learned that any antibiotic can do it.
The authors comment that there is conclusive evidence that C. diff is becoming more virulent worldwide. This is based not only on their own study, but others in Canada and Europe as well. They were not able to determine specifically why this is so:
Overall, the population-based data in our study provide supporting evidence for the clinical impression that the nature of C difficile colitis in hospitalized patients is changing,19 but did not allow determination of the cause of the change. A recent epidemic of C difficile colitis in Quebec was attributed to a particular strain of C difficile: toxinotype III, North American PFGE type 1, and PCR ribotype 027 (NAP1/027). This strain carries the binary toxin gene cdtB (cytolethal distending toxin B gene) and an 18–base pair deletion in tcdC; it hyperproduces toxins A and B.6, 8, 20-21 In addition, this hypervirulent strain is also associated with increased disease severity6, 21 and possibly transmissibility and has caused outbreaks in England,22 Canada,23 and the United States.
They add that resistance to traditional first-line antibiotics, such as metronidazole (Flagyl) is increasing. There is some evidence that use of fluoroquinolone antibiotics may increase the risk.
The authors do not provide specific recommendations, other than to say that increased recognition of the problem is needed.
