Introduction Clostridium difficile associated diarrhoea (CDAD) is an important hospital acquired infection. In 2008–2009 Co. Durham had one of the highest reported annual incidence of CDAD with 232 cases, 74.4 cases/100 000 bed days. Following strict antibiotic stewardship in 2009, we set out to examine the changes to the hospital based epidemiology of CDAD in our three hospitals over a 12-month period.
Methods Between June 2010 and May 2011, 70 patients with positive stool C difficile toxin were identified from the Microbiology database, and 56 case notes reviewed. Patient demographics, clinical symptoms, risk factors, severity, treatment for CDAD, and multi-disciplinary team decisions were recorded. Clinical outcomes including length of stay, treatment, mortality, and relapses were analysed and compared to standard hospital episode statistics (HES).
Results The annualised hospital incidence of CDAD was 70/20 000 admissions, age range 2–100 yrs (mean 75.5, M: F). 76.8% patients were older than 70 yrs. 43% had received antibiotics prior to admission and 35 (62%) patients were commenced on antibiotics in hospital. The top 5 were Amoxicillin, Co-amoxiclav, Flucloxacillin, Cephalexin and Trimethoprim. 62% of these had received one course of antibiotic, and 30% two or more courses. 39% patients had a previous admission to hospital in the preceding 12 weeks, 46.4% were taking a PPI and 35.7% a laxative. C difficile was confirmed by both toxin and GDH positivity in 80.4%, and by toxin positivity only in 19.6%. Total length of stay ranged from 51 days (16%). A positive diagnosis was made in 80% patients, but severity was not always recorded. Stool charts were completed in 70%, serum lactate checked in 10% and abdominal x-ray done in 30%. Only 25% patients were seen by an MDT member. 78.5% pts were treated, 30/44 (68%) with Metronidazole and 11/44 (25%) with Vancomycin as first line drugs. 3/44 patients received both drugs initially. 30.4% pts received ≤7 days, 50% upto 14 days and 19.6% ≥14 days treatment. All cause mortality was 25%, almost entirely in the elderly. 7% had a recurrence, all treated by Vancomycin and pulsed/tapered regimes and probiotics were used infrequently.
Conclusion CDAD continues to be an important hospital acquired infection with a significant increase in hospital length of stay and high mortality rates, especially in the elderly. This study indicates that a significant proportion of CDAD may be acquired in the community. Adherence to national recommendations for management and involvement of the MDT needs to be encouraged to improve outcomes.
Competing interests None declared.
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