Clostridium difficile Cases Increasing

href="http://www.webmd.com/digestive-disorders/tc/Clostridium-Difficile-Colitis-Overview"
rel="tag">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 href="http://scienceblogs.com/corpuscallosum/2007/07/uk_study_shows_benefit_from_pr.php">posted
about  the same topic.  face="Helvetica, Arial, sans-serif">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 face="Helvetica, Arial, sans-serif">C.
diff. colitis.  I like
to blog about medical interventions that are extremely inexpensive, yet
yield large benefits.



The  face="Helvetica, Arial, sans-serif">Archives of
Surgery face="Helvetica, Arial, sans-serif"> 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.

href="http://archsurg.ama-assn.org/cgi/content/abstract/142/7/624">

rev="review"
href="http://archsurg.ama-assn.org/cgi/content/abstract/142/7/624">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

face="Helvetica, Arial, sans-serif">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, rel="tag" href="http://en.wikipedia.org/wiki/Clindamycin">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:

face="Helvetica, Arial, sans-serif">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 href="http://en.wikipedia.org/wiki/Quinolone" rel="tag">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.