Pharmacotherapy in the treatment of Clostridium difficile : impact on clinical practice

Abstract

Clostridium difficile is a pathogen accounting for 20-30% of cases of antibiotic-associated diarrhoea and is the most common cause of hospital-acquired diarrhoea. Transmission takes place by faecal-oral route. Colonization can be symptomatic or asymptomatic. Risk factors for C. difficile infection (CDI) include: recent or concomitant antibiotic exposure, older age, length of hospital stay, gastric acid suppression and immunosuppression. This study aims to propose a framework for C. difficile culturing and antibiotic sensitivity testing with standardization of this testing procedure on the clinical setting and to identify risk factors for CDI and carriage of this infection. Sixteen publications about C. difficile culturing and antibiotic sensitivity testing were reviewed and cost estimates for the materials needed to run the tests were collected. Medical records of patients with the following inclusion criteria were reviewed: over 18 years of age, inpatients at Mater Dei Hospital (MDH) or Sir Anthony Mamo Oncology Center (SAMOC) after the implementation of the “Algorithm for Clostridium difficile infection (CDI) investigation and results interpretation in adults” and having Glutamate Dehydrogenase antigen (GDH) positive faecal specimens. In a final phase, data available locally between 2015 and 2016 was analysed to provide an overview of the epidemiological situation of CDI. A standard procedure for C. difficile culturing and antibiotic sensitivity testing in the clinical setting was proposed with a local cost of €116.30 per sample. Out of a population of 241 patients, 130 met the inclusion criteria; of whom 67 patient medical records were reviewed. Risk factors for the infection to progress to active disease were assessed.

Non-adherence to the local algorithm was detected in 13 cases. In 2015, fifty-six samples tested C. difficile toxin positive, compared to 111 in 2016. Recent antibiotic exposure and chronic kidney disease were identified as key factors for C. difficile colonization to progress to the active infection. Incidence of CDI has increased from 2015 to 2016. According to the developed framework, it is being proposed that C. difficile culturing and antibiotic sensitivity testing is indicated to be performed in recurrent cases, immunocompromised patients, C. difficile outbreaks and for the potential establishment of a local surveillance program. The delivery of educational programs and relocation of infected patients to the Infectious Disease Unit (IDU) is recommended to improve adherence to the local algorithm. There is need for the implementation of gastric acid suppression therapy routine assessment programs to reflect on necessity for long term treatment with gastric acid suppressant drugs and a need to decrease empiric treatment with fluoroquinolones. Implementation measures to prevent contamination from C. difficile carriers were deemed necessary. The female gender was designated as a potential risk factor for CDI in the Maltese population and suggested for further investigations.