Clostridium difficile infections in a Canadian tertiary care hospital before and during a regional epidemic associated with the BI/NAP1/027 strain

Abstract

Since 2002, an epidemic of Clostridium difficile infections has occurred in southern Quebec, Canada. At Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada, the incidence of C. difficile infections increased from 11/1,000 admissions (1999 to 2002) to 27/1,000 admissions (2003 to 2005). We compared the exposures and outcomes for patients infected with strains with different ribopatterns isolated before (n = 55) and during (n = 175) the epidemic, as well as the in vitro activities of antibiotics against those isolates. During the preepidemic period, 46 isolates (84%) were of ribotype 001, 1 was of ribotype 027, and 8 were of other ribopattern types. During the epidemic period, ribotype 027 strains accounted for 140 (80%) isolates; 26 (15%) were of ribotype 001, and 7 were of other ribopattern types. Ribotype 027 strains were highly resistant to fluoroquinolones (FQs) but were susceptible to clindamycin. A pattern of prior specific antibiotic exposure that selected for antibiotic-resistant ribotype C. difficile infections was observed for FQs (ribotype 027) and clindamycin (ribotype 001). The rate of mortality was higher among older patients, those with a high Charlson comorbidity index, and those with longer previous hospitalizations. By multivariate analysis, patients infected with ribotype 027 were twice as likely to die within 30 days of diagnosis than patients infected with other ribotypes (adjusted odds ratio, 2.06; 95% confidence interval, 1.00 to 4.22). The observations from this study support the notion that continued selective antibiotic pressure resulted in the superimposition of the hypertoxigenic ribotype 027 clone on top of the prior dominant ribotype 001 clone in a setting of preexisting high endemicity, thus leading to the high rates of morbidity and mortality seen in the Quebec outbreak. Stringent antibiotic stewardship measures, combined with aggressive infection control, are required to curtail the epidemic of C. difficile infections.

FIG. 1.

(a) Monthly rates of admissions at Hôpital Maisonneuve-Rosemont for a first episode of C. difficile infection, January 1999 to March 2007 (source, MedEcho, Institut National de Santé Publique du Québec). (b) Ribotype frequencies of isolates during the two study periods (55 patients in 2000 and 2001 and 175 patients in 2003 and 2004).

FIG. 2.

Antibiotic consumption at Hôpital Maisonneuve-Rosemont (April 2000 to March 2007). Cephalosporins 1, cephalexin, cefadroxil, and cefazolin; Cephalosporins 2-3, cefuroxime, cefoxitin, ceftriaxone, and ceftazidime; Macrolides, erythromycin, clarithromycin, and azithromycin. Gatifloxacin was introduced on the formulary in November 2001 and was replaced by moxifloxacin in June 2005.