No Connection Between C Difficile Colonization and Diarrhea, Length of ICU Stay

Marcio Fernando Spagnol

New research shows no association between clostridium difficile colonization and diarrhea or length of stay, among patients in the intensive care unit (ICU).

A team, led by Marcio Fernando Spagnol, Universidade Federal do Rio Grande do Sul, Medical Science Post-Graduation Program, identified the frequency of C difficile colonization and its impact on clinical outcomes for patients admitted to intensive care units in Brazil.

A Growing Problem

C difficile rates have increased in the US in the last 10 years and are currently the main cause of healthcare-associated infections.

Recently in Brazil, investigators estimated 11.8% of hospitalized patients with diarrhea had CDI.

While research has focused on characterizing risk factors associated with the colonization by toxigenic C difficile and occurrence of CDI, very few involve ICU patients in developing countries.

“Since ICU patients have multiple risk factors for colonization (prolonged hospitalization, antibiotic use, and severity factors), a high frequency of colonization might be anticipated, but data on this population are even more sparse,” the authors wrote.

Patients in Brazil

In the prospective cohort study, the investigators screened 92 patients in ICUs at 2 tertiary teaching hospitals in Brazil between November 21, 2018 to December 20, 2018 to measure toxigenic C difficile colonization, variables associated, and the clinical course of colonized patients admitted to the ICU. They also reported the susceptibility profile and the molecular characterization of C difficile using whole genome sequencing.

The investigators collected patient variables at ICU admission and patients with diarrhea at admission, readmissions, postoperative ICU stays, previous colectomy, or refusals to participate were excluded.

The team also collected rectal swabs from all participants and stool samples from individuals worth diarrhea on the day of inclusion.

In addition, 19.6% (n = 18) of patients had diarrhea during follow-up. This patient subpopulation was associated with longer hospital stays (17 days, IQR, 10–28 versus 39 days IQR, 25–64; P <0.001), but there was no association between diarrhea and other variables.

Of the 92 patients screened, 17.3% (n = 16) colonized by C difficile, according to qPCR. In addition, only 4 of the 18 patients with diarrhea were positive for toxigenic C difficile.

This patient population had a higher Simplified Acute Physiology Score III (SAPS III).

However, there was no association between C difficile colonization with diarrhea or mortality.

After sequencing the different C difficile strains, the investigators found they belonged to clade 1 and presented high vancomycin-resistant rates.

“In conclusion, despite the high rate of colonization with toxigenic C. difficile, there was no correlation between colonization and diarrhea, length of stay or death,” the authors wr0te. “In conclusion, despite the high rate of colonization with toxigenic C. difficile, there was no correlation between colonization and diarrhea, length of stay or death.

“However, the high prevalence of colonization and rates of vancomycin resistance raise concerns about infection control practices and should be better evaluated.”

Limitations

The investigators did identify some limitations in the study. For example, it was likely underpowered to detect significance because of the small difference in the development of diarrhea observed in colonized and non-colonized patients (22% vs 16%; P = 0.508). The investigators also obtained a small number of stool samples, precluding anaerobic culture and molecular characterization of more isolates.

The study, “High rate of Clostridioides difficile colonization in patients admitted to intensive care: A prospective cohort study,” was published online in Anaerobe.