The national surveillance of Clostridium difficile in Denmark

Transcription

1 The national surveillance of Clostridium difficile in Denmark Katharina E. P. Olsen, PhD (PharmD) National Reference Laboratory for Enteropathogenic Bacteria Departement of Microbiology and Infection control Statens Serum Institut Copenhagen, Denmark

2 Surveillance algorithm I. Mandatory laboratory notification of Clostridium difficile cases to Statens Serum Institut II. Mandatory submission of isolates to SSI for further typing: Criteria: Moxifloxacin-R Suspicion of outbreak Severe clinical course Genes for A, B and CDT but no CD027 marker Genotypic detection of C. difficile (CD) toxins and tcdc mutations* Tandem repeat sequence typing Persson, JCM (2011)*

3 The Danish criteria for submission of isolates ECDC criteria New criterion in DK in 2012 Moxifloxacin-R Severe clinical course of CDI Suspicion of outbreak Positive for the genes codinga, B and binarytoxin, but negative for CD027 marker ( 117) Decrease in submission of isolates because of change in the primary diagnostics towards molecular biology techniques directly on stool samples. As a consequence stool samples are also accepted for submission in the surveillance programme. 3

4 Binary toxin plays a central role in risk assessment Toxins and CD027 marker Predicts higher 30 days mortality Predicts recurrence A B CDT Increased adhesion bp Mutations in tcdc Caco-2 cells and binary toxin Choice of antibiotics Metronidazole, when A and B. Binary in addition, vancomycin Isolation of patients Schwan, PLoS Pathogens (2009); Stewart, J Gastrointest. Surg. (2012); Bacci, EID (2011). 4

5 KAPLAN-MEIER CURVE ACCORDING TO TYPE OF INFECTION CD 027 and CD non-027 almost overlap for the first 30 days 28% 17% 14% Large increase in the mortality in the first 30 days for all groups Bacci, EID (2011)

6 Clostridium difficile 027 in Denmark Increase of CD027 in Capital region in 2013 Decrease of CD027 in Region Seeland in 2012 From 2011 data are based on notification (no isolates) for most of Capital region 6

7 Non-027 in submitted isolates

8 A study on risk factors and clinical symptomatology of Clostridium difficile i the community

9 Objectives To identify risk factors and describe clinical characteristics of C. difficile infection in patients attending their general practitioner because of diarrhea or other gastrointestinal symptoms. < 2 years of age 2 years of age

10 Prospective matched case-control and cohort study Patient questionnaire (clinical symptoms, co-morbidity, admission to hospital, contact to outpatient clinic, nonprescription medication, food consumption, contact with animals and infants etc.) patients received a questionnaire - Response rate was 50% Matching criteria: age, gender, uptake area and season Prescription medication for systemic use (by personal ID number; data from all Danish pharmacies submitted to the Danish Medicines Agency) Study period: Aug Feb 2011

11 Statistical methods Conditional logistic regression (SAS, ver 9.1) to calculate risk factor for CDI Exposure variables from questionnaires and medication data Univariate analysis If covariates significant at 90% level Multivariate analysis Test for interactions and multiple imputations of missing values (STATA 10)

12 Case definitions CDI (Clostridium difficile infection): Patients with diarrhea or other gastrointestinal symptoms and a faecal specimen positive for toxigenic C. difficile. diarrhea: > 3 daily unformed stools. Non-CDI: Patients with diarrhea and a faecal specimen culture negative for C.difficile. CA-CDI (community acquired): not discharged from an HCF at least 12 weeks prior to onset. onset <48 hrs after admission to a healthcare facility (HCF). HCA-CDI (healthcare acquired): onset >48 hrs after admission to an HCF. onset within four weeks after discharge.

13 Co-pathogens investigated Virus Adenovirus, astrovirus, norovirus, rotavirus and sapovirus. Bacteria Salmonella, Campylobacter, Shigella, Yersinia enterocolitica, Aeromonas, diarrheagenic E. coli. Parasites Giardia duodenalis, Cryptosporidium, Dientamoeba fragilis, Entamoeba dispar, Entamoeba histolytica.

14 Uptake area Funen Rural parts of Zealand close to the capital region Capital region

15 Demographics No. of patients < 2 years 2 years Case Case Females (%) Median age (yrs) Age range (yrs) Interquartile range (yrs)

16 Origin of infection and toxin gene profile Cases <2 years 2 years Origi HCA 0 20 CA Unknown 3 6 Toxin genes (%) A, B & CDT 7 21 A & B Non-toxigenic 32 19

17 Age and origin of CDI

18 Age and gene toxin profile

19 Co-pathogens < 2 years 2 years Case (%) (%) Case (%) (%) Virus 58 (50) 105 (51) 13 (10) 27 (12) Norovirus 20 (17) 51 (25) 6 (5) 15 (7) Rotavirus 6 (5) 18 (9) 1 (0.8) 3 (1) Adenovirus 13 (11) 11 (5) 4 (3) 1 (1) Bacteria 28 (23) 53 (25) 20 (14) 32 (13) A/EEC# 22 (18) 36 (17) 3 (2) 9 (4) Campylobacter 1 (0.8) 7 (3) 6 (4) 18 (7) EPEC 3 (2) 10 (5) 0 (0) 0 (0) Parasites 6 (5) 24 (12) 4 (3) 53 (24) Dientamoeba fragilis# # candidate pathogens 5 (4) 20 (10) 3 (2) 43 (19)

20 Co-pathogens < 2 years 2 years Case (%) (%) Case (%) (%) Virus 58 (50) 105 (51) 13 (10) 27 (12) Bacteria 28 (23) 53 (25) 20 (14) 32 (13) Parasites 6 (5) 24 (12) 4 (3) 53 (24) Generally accepted pathogens 62 (53) 120 (60) 30 (23) 60 (26) Detecting a generally accepted co-pathogen in CDI patients < 2 years vs 2 years of age: OR 3.9; 95% CI:

21 Risk factors for CDI Univariate matched analysis Illness Hospital Medication Case (N= ) < 2 years 2 years (N= ) Case vs OR 95% CI Case (N= ) (N= ) Case vs OR 95% CI Co-morbidity 2 (2) 1 (1) (39) 64 (37) Hospitalization 13 (13) 18 (13) (35) 15 (9) * Outpatient clinic 19 (19) 22 (16) (31) 31 (20) * Antibiotic treatment (DMA) 19 (18) 19 (14) (48) 23 (13) *

22 Risk factors for CDI Univariate matched analysis < 2 years 2 years Food Case Case vs Case Case vs (N=95-102) (N= ) OR 95% CI (N=93-116) (N= ) OR 95% CI Beef 71 (70) 97 (70) (85) 124 (71) * Pork 73 (72) 100 (72) (88) 132 (77) * Lamb 8 (8) 3 (2) (6) 17 (12) Poultry 71 (70) 86 (63) (82) 129 (75) Fish 58 (57) 85 (63) (74) 118 (70) Egg 32 (31) 47 (34) (65) 116 (67) Cabbage 49 (49) 66 (49) (57) 110 (64) Other vegetables 94 (90) 124 (89) (97) 170 (96) Fruit 99 (94) 134 (94) (88) 164 (92)

23 The Broccoli theory sulforaphane Exhibits anticancer, antidiabetic and antimicrobial properties

24 Contact with animals Risk factors for CDI Univariate matched analysis Case (N=86-104) < 2 years 2 years (N= ) Case vs OR 95% CI Case (N= ) (N= ) Case vs OR 95% CI All animals 74 (71) 90 (63) (66) 111 (64) In a multivariate analysis of patients < 2 yrs of age: Contact with animals: OR 8.1; 95% CI: Dog 54 (60) 61 (51) (55) 83 (51) Cat 30 (35) 41 (35) (36) 65 (40) Guinea pig 2 (2) 2 (1) (2) 9 (5) Rabbit 4 (4) 11 (8) (4) 13 (8) Horse 7 (7) 6 (4) (8) 15 (9) Cattle 2 (2) 4 (3) (0) 5 (3) - - Pig 2 (2) 2 (1) (1) 2 (1) Contact with infants for patients >15 years: OR 0.5; 95% CI:

25 PCR ribotypes and age

26 PCR ribotypes and origin

27 Risk factors for CDI Multivariate matched analysis 2 years Drugs Hospital Beef OR 95% CI P Antibiotic treatment < Hospitalization < Intake of beef at least weekly

28 Prescription medication (DMA) Gastric acid suppressive agents: Risk factors for CDI Univariate matched analysis Case (N=105) < 2 years 2 years (N=139) Case vs OR 95% CI Case (N=121) (N=175) Case vs OR 95% CI Magnesiumoxid (3) 1 (1) Proton pump inhibitors 0 2 (1) (17) 38 (22) H 2 antagonist (1) Laxatives 2 (2) 1 (1) (2) 4 (2) Loperamid 0 1 (1) (1) ASA (acetylsalicylic acid) NSAID (non-steroid antiinflammatory drugs) (9) 18 (10) (19) 17 (10) *

29 Risk factors for CDI Univariate matched analysis Prescription medication (DMA) Case (N=105) < 2 years 2 years (N=139) Case vs OR 95% CI Case (N=121) (N=175) Case vs OR 95% CI All antimicrobials 19 (18) 19 (14) (48) 23 (13) * Penicillins: Penicillins with extended spectrum # Phenoxymethylpenicillin 10 (10) 13 (9) (14) 3 (2) * 8 (8) 7 (5) (13) 4 (2) * Dicloxacilin (16) 2 (1) * Cephalosporins Clindamycin (6) # i.e. pivmecillinam, (piv)ampicillin, amoxicillin and amoxicillin/clavulanic acid cont.

30 Risk factors for CDI Univariate matched analysis Prescription medication (DMA) Fluoroquinolones Case (N=105) < 2 years 2 years (N=139) Case vs OR 95% CI Case (N=121) (N=175) Case vs OR 95% CI Ciprofloxacin 1 (1) (3) 7 (4) Moxifloxacin (1) Macrolides 1 (1) 1 (1) (6) 1 (1) Sulfamethizol (1) - - Trimethoprim 0 1 (1) (1) - - Metronidazole 1 (1) 1 (1) (9) 2 (1) *

31 Risk factors for CDI Multivariate matched analysis 2 years Prescription medication (DMA) OR 95% CI P Penicillins with extended spectrum Phenoxymethyl penicillin Dicloxacillin

32 Supplementary analyses Consumption of beef was associated with CDI in patients 2 years of age, also when multivariate analysis was performed in the following subgroup: only patients with no generally accepted enteropathogens (OR 4.6; 95% CI: ). No interactions were found between the covariates in the multivariate model. Exclusion of co-pathogens in the univariate analyses did not change the trends observed. Multiple imputations of missing values (~ 10 % of patients) in the multivariate analyses (questionnaire and prescription medication data) did also not alter the trends observed.

33 Clinical characteristics < 2 years 2 years CD No CD P CDI Non-CDI P (N=22-38) (N=86-120) (N=70-95) (N=50-60) Bloody stools 4 (11) 4 (3) (15) 6 (10) 0.3 Slimy stools 24 (65) 70 (63) (62) 18 (33 ) * Stool frequency >10 per day 6 (17) 31 (27) (42) 23 (43) 0.9 Duration of diarrhea >15 days 13 (59) 37 (40) (73) 14 (27) < * Vomiting 13 (35) 67 (58) 0.009* 14 (16) 24 (44) * Stomache ache 15 (60) 33 (50) (75) 43 (77) 0.8 Fever > 38 C 16 (44) 59 (54) (26) 29 (58) * Weight loss 16 (50) 50 (58) (76) 40 (80) 0.3 Had to stay in bed 3 (8) 22 (19) (43) 38 (63) 0.04* Illness absenteeism 16 (53) 83 (78) 0.04* 33 (45) 39 (76) 0.006* Antibiotic treatment because of gastroenteritis 6 (16) 9 (8) (62) 22 (38) 0.02*

34 Conclusion (1) Predictors of CDI in patients 2 years of age Hospitalization Narrow-spectrum penicillins Beef consumption For patients 2 years of age 23% were neither hospitalized nor had received any antibiotics prior to onset of infection. Reduced to 16% when only cases with CD as the only pathogen were included. Predictors for patients <2 years of age with CD In a subgroup, contact with animals was a risk factor.

35 Conclusion (2) Clinical characteristics: Patients 2 years of age persistent diarrhea, weight loss, stomache ache, slimy stools. Patients <2 years of age similar although less pronounced Comparing CDI patients 2 years of age with patients with other causes of infectious gastroenteritis: persistent diarrhea (P <0.0001) and slimy stools (P=0.0004) were more often reported in CDI patients. Otherwise milder symptoms.

36 Acknowledgements Conductor of the study Lillian Søes, MD, PhD fellow Laboratory databases Steen Hoffmann, MD Epidemiology Kåre Mølbak, MD, DMSc Steen Ethelberg, MSc, PhD Diagnostics and molecular typing Mia Torpdahl, MSc, PhD Blenda Böttiger, MD, DMSc Sanne Søgaard Nielsen, MSc Henrik Vedel Nielsen, MSc, PhD Søren Persson, MSc, PhD Odense University hospital Hanne M. Holt, MD, PhD Co-conductor Michael Kemp, MD, DMSc Supervisor Roskilde University Viggo Andreasen, MSc, PhD Supervisor SSI Katharina E. P. Olsen, PhD, PharmD. Supervisor