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Comparative Study
. 2017 Aug 1;65(3):433-441.
doi: 10.1093/cid/cix338.

Comparison of Control of Clostridium difficile Infection in Six English Hospitals Using Whole-Genome Sequencing

David W Eyre  1 , Warren N Fawley  2 , Anu Rajgopal  3 , Christopher Settle  4 , Kalani Mortimer  5 , Simon D Goldenberg  6 , Susan Dawson  7 , Derrick W Crook  1 , Tim E A Peto  1 , A Sarah Walker  1 , Mark H Wilcox  2
Affiliations
Comparative Study

Comparison of Control of Clostridium difficile Infection in Six English Hospitals Using Whole-Genome Sequencing

David W Eyre et al. Clin Infect Dis. .

Abstract

Background: Variation in Clostridium difficile infection (CDI) rates between healthcare institutions suggests overall incidence could be reduced if the lowest rates could be achieved more widely.

Methods: We used whole-genome sequencing (WGS) of consecutive C. difficile isolates from 6 English hospitals over 1 year (2013-14) to compare infection control performance. Fecal samples with a positive initial screen for C. difficile were sequenced. Within each hospital, we estimated the proportion of cases plausibly acquired from previous cases.

Results: Overall, 851/971 (87.6%) sequenced samples contained toxin genes, and 451 (46.4%) were fecal-toxin-positive. Of 652 potentially toxigenic isolates >90-days after the study started, 128 (20%, 95% confidence interval [CI] 17-23%) were genetically linked (within ≤2 single nucleotide polymorphisms) to a prior patient's isolate from the previous 90 days. Hospital 2 had the fewest linked isolates, 7/105 (7%, 3-13%), hospital 1, 9/70 (13%, 6-23%), and hospitals 3-6 had similar proportions of linked isolates (22-26%) (P ≤ .002 comparing hospital-2 vs 3-6). Results were similar adjusting for locally circulating ribotypes. Adjusting for hospital, ribotype-027 had the highest proportion of linked isolates (57%, 95% CI 29-81%). Fecal-toxin-positive and toxin-negative patients were similarly likely to be a potential transmission donor, OR = 1.01 (0.68-1.49). There was no association between the estimated proportion of linked cases and testing rates.

Conclusions: WGS can be used as a novel surveillance tool to identify varying rates of C. difficile transmission between institutions and therefore to allow targeted efforts to reduce CDI incidence.

Keywords: Clostridium difficile; infection control; surveillance; transmission; whole-genome sequencing.

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Figures

Figure 1.
Figure 1.
Proportion of cases linked to a previous case by hospital. A, Proportion of potentially toxigenic cases linked to a previous potentially toxigenic case, by hospital and recipient fecal-toxin status. B, Proportion of fecal-toxin-positive cases linked to a previous fecal-toxin-positive case. C, Proportion of all Clostridium difficile (potentially toxigenic or nontoxigenic) linked to previous C. difficile case. D, Proportion of potentially toxigenic cases linked to a previous potentially toxigenic case, by hospital and 90 day period (comparing subsequent quarters to quarter 2 by hospital, hospital 6, quarter 3, P = .08, otherwise P > .36). Abbreviation: SNP, single-nucleotide polymorphism.
Figure 2.
Figure 2.
Proportion of potentially toxigenic cases linked to a previous potentially toxigenic case by hospital and number of sequences obtained. Abbreviation: SNP, single-nucleotide polymorphism.
Figure 3.
Figure 3.
Relationship between the proportion of cases linked to a previous case by Clostridium difficile testing rate. A, The proportion of potentially toxigenic cases linked to a previous potentially toxigenic case. B, The proportion of fecal-toxin-positive cases linked to a previous fecal-toxin-positive case and includes comparisons from previous published data from Oxford (by calendar year) and Leeds (2010–12). Abbreviation: SNP, single-nucleotide polymorphism.
Figure 4.
Figure 4.
Proportion of cases linked to a previous case by hospital, adjusted for ribotype (A), and by ribotype, adjusted for hospital (B). In panel B, * indicates P < .05 compared to the “Other” ribotype category, and ** P < .01. Abbreviation: SNP, single-nucleotide polymorphism.
See this image and copyright information in PMC

References

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