Clostridium difficile Bacteremia, Taiwan | CDC EID

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Volume 16, Number 8–August 2010
Synopsis
Clostridium difficile Bacteremia, Taiwan1
Nan-Yao Lee, Yu-Tsung Huang, Po-Ren Hsueh,2 and Wen-Chien Ko2

Author affiliations: National Cheng Kung University Hospital and Medical College, Tainan, Taiwan (N.-Y. Lee, W.-C. Ko); and National Taiwan University Hospital and College of Medicine, Taipei, Taiwan (Y.-T. Huang, P.-R. Hsueh)

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Abstract
To determine clinical characteristics and outcome of patients with Clostridium difficile bacteremia (CDB), we identified 12 patients with CDB in 2 medical centers in Taiwan; all had underlying systemic diseases. Five had gastrointestinal diseases or conditions, including pseudomembranous colitis (2 patients); 4 recalled diarrhea, but only 5 had recent exposure to antimicrobial drugs. Ten available isolates were susceptible to metronidazole and vancomycin. Five isolates had C. difficile toxin A or B. Of 5 patients who died, 3 died of CDB. Of 8 patients treated with metronidazole or vancomycin, only 1 died, and all 4 patients treated with other drugs died (12.5% vs. 100%; p = 0.01). C. difficile bacteremia, although uncommon, is thus associated with substaintial illness and death rates.
Clostridium difficile is well recognized as the etiologic agent of pseudomembranous colitis and has been implicated as the cause of 10%–25% of cases of antimicrobial drug–associated diarrhea (1 ). The pathogen has been responsible for numerous recent hospital-based epidemics and is also emerging in the community (2 ). The clinical features, disease spectrum and pathogenesis, and optimal treatments of C. difficile–associated diarrhea have been well studied. In contrast, reports of the isolation of C. difficile in body sites other than the intestines, or extraintestinal infections, have been anecdotal (3,4 ). Extracolonic manifestations of C. difficile infections reported were variable, including bacteremia, osteomyelitis, visceral abscess, empyema, reactive arthritis, pyelonephritis, prosthetic joint infection, and skin and soft tissue infection (3–10 ). Most cases of extracolonic C. difficile infections have been preceded by gastrointestinal events, either C. difficile colitis or surgical and anatomic disruption of the colon (4 ).

Recently, Libby and Bearman reviewed the literature on bacteremia caused by C. difficile (6 ). Most cases were identified from individual case reports. However, as the incidence of C. difficile infection increases, an increase in cases of C. difficile bacteremia (CDB) is likely (10 ). Knowledge of the clinical signs and symptoms of these extracolonic manifestations of bloodstream infections will be useful in patient care and could improve clinical outcomes (4 ). To outline the spectrum and clinical significance of CDB, we report 12 cases of CDB over a recent 10-year period at 2 medical centers in Taiwan and review the literature published in English.

Patients
Patients with blood cultures positive for C. difficile at 2 teaching hospitals (National Cheng Kung University Hospital, a 1,100-bed tertiary care hospital in southern Taiwan and National Taiwan University Hospital, a 2,800-bed tertiary care hospital in northern Taiwan) during January 1989 through February 2009, were retrospectively identified from laboratory records, and their medical records were reviewed. If a patient experienced >1 episode of CDB, only information about the first episode was included. Information about age, sex, underlying diseases, clinical course, antimicrobial drug therapy, and clinical outcome was recorded in a case-record form.

We conducted a literature review to find relevant articles published between January 1, 1962, and August 31, 2009, by querying the PubMed database using the keywords "Clostridium difficile," "bacteremia," "sepsis," and "bloodstream infection." The references of available articles were surveyed for additional cases.

Definitions
Underlying conditions were stratified on the basis of the McCabe and Jackson score (11 ) and the comorbidity score of Charlson et al. (12 ). Severity of illness was evaluated on the first day of bacteremia onset by means of the Acute Physiology and Chronic Health Evaluation II Score (13 ), Simplified Acute Physiology Score II (14 ), and the Pittsburgh bacteremia score (15 ). The physiologic response to bacteremia was categorized as severe sepsis if the patient met the criteria for severe sepsis specified by the American College of Chest Physicians/Society for Critical Care Medicine Consensus Conference Committee (16 ). Immunosuppressive therapy was defined as the receipt of corticosteroid treatment (10 mg/day or an equivalent dosage) for >2 weeks of antineoplastic chemotherapy or antirejection medication within 30 days before admission. Sepsis-related death was defined as the death of a patient with a clinical course that suggested persistently active infection if the patient had no other obvious explanation for the death.

Bacteremia was defined as the presence of an organism in a blood culture specimen. Clinically significant bacteremia was defined as >1 positive blood culture and clinical features compatible with fever and sepsis syndrome; patients with noteworthy bacteremia were included in this study. An episode of bacteremia was considered to be hospital acquired if a bacteremic episode was noted at >48 hours after hospitalization; healthcare associated if it occurred within 48 hours of hospitalization in patients with extensive contact with the healthcare system (such as nursing home residence, organ transplantation, hemodialysis dependence, presence of an indwelling intravascular catheter, or surgery within the previous 30 days), or the patients had been transferred from another hospital or long-term care facility; or community acquired if it occurred <48 hours of admission in patients without extensive healthcare contact. In the case of secondary bacteremia, a primary focus of infection was defined according to the criteria of the Centers for Disease Control and Prevention (17 ).

Antimicrobial drug therapy in the preceding 30 days was documented through a review of medical records. Previous antimicrobial drug therapy was defined as the receipt of an oral or parenteral antimicrobial agent for >72 hours within the preceding 2 months.

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Suggested Citation for this Article
Suggested citation for this article: Lee N-Y, Huang Y-T, Hsueh P-R, Ko W-C. Clostridium difficile bacteremia, Taiwan. Emerg Infect Dis [serial on the Internet] 2010 Aug [ date cited]. http://www.cdc.gov/EID/content/16/8/1204.htm

DOI: 10.3201/eid1608.100064

1This study was presented in part at the Annual Meeting of the Infectious Disease Society of Taiwan, Taipei, Taiwan, January 9–10, 2010.
2These authors contributed equally to this article.