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Antimicrob. Agents Chemother. doi:10.1128/AAC.00146-08
Copyright (c) 2008, American Society for Microbiology and/or the Listed Authors/Institutions. All Rights Reserved.

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

Department of Microbiology, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada; Department of Microbiology and Immunology, University of Montreal, Québec, Canada; Department of Microbiology and Infectious Diseases, University of Calgary, Alberta, Canada; Department of Pharmacy, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada; University of Sherbrooke, Québec, Canada

^* To whom correspondence should be addressed. Email: ac.labbe{at}umontreal.ca.

	Abstract

Since 2002, an epidemic of Clostridium difficile infections (CDI) has occurred in southern Quebec. At Hôpital Maisonneuve-Rosemont, Montreal, CDI incidence increased from 11/1000 admissions (1999-2002) to 27/1000 admissions (2003-2005). We compared exposures and outcomes of patients infected with different ribopattern strains isolated before (n=55) and during (n=175) the epidemic, as well as in vitro activities of antibiotics against those isolates. During the pre-epidemic period, 46 isolates (84%) were of ribotype 001, 1 of ribotype 027, and 8 of other ribopattern types. In the epidemic period, ribotype 027 strains accounted for 140 (80%) isolates; 26 (15%) were of ribotype 001 and 7 of other ribopattern types. Ribotype 027 strains were highly resistant to fluoroquinolones (FQ) but susceptible to clindamycin. A pattern of prior specific antibiotic exposure selecting for antibiotic-resistant ribotype C. difficile infection was observed for FQ (ribotype 027) and clindamycin (ribotype 001). Mortality was higher in older patients, those with a high Charlson co-morbidity index and those with longer previous hospitalization. In multivariate analysis, patients infected with ribotype 027 were twice as likely to die within 30 days of diagnosis than patients with other ribotypes (AOR: 2.06 95%CI: 1.00-4.22). The observations in 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 pre-existing 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 CDI epidemic.