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P766 Clostridium difficile in Australia
S190 (>7 days) among group B (p = 0.040 and 0.019, respectively) but not among group A patients. Conclusions: Differences were detected between the two groups of patients regarding nosocomial acquisition, prior hospitalisation, prior antimicrobial therapy, length of diarrhoea, and final outcome. These differences are considered useful for optimisation of measures for prevention, control and treatment of CDAD. P764 Mortality of patients with antibiotic-associated diarrhoea – the impact of Clostridium difficile
17th ECCMID / 25th ICC, Posters patient who presented pseudomembranous colitis and to whom MTZ was given simultaneously with VA. None of the 17 patients presented VRE bacteraemia. Interestingly, 7/67 Cd-positive patients who were treated successfully for their intestinal infection (five with MTZ and two with VA) presented VRE in their stool samples after their treatment. Conclusions: In our hospital co-existence of Cd and VRE is high. This may result in the emergence of vancomycin resistant Cd posing new challenges in the management of hospital associated diarrhoea. So appropriate antibiotic policy and strict enteric precautions should be implemented to break the vicious circle between these two bacteria.
J. Bishara, S. Pitlik, Z. Samra (Petah-Tiqva, IL) P766 Clostridium difficile in Australia Background: Clostridium difficile infection is implicated in 20 to 30% of cases of antibiotic-associated diarrhoea. Previous studies have shown conflicting results relating to mortality attributable to C. difficile infection. The objective of this study was to determine the impact of C. difficile infection on short- and long-term mortality in hospitalised patients with antibiotic-associated diarrhoea. Methods: All patients hospitalised from October 2003 to January 2004 who had antibiotic-associated diarrhoea and underwent stool enzyme immunoassay for C. difficile TOX A/B were followed prospectively. For univariate survival analysis the Kaplan-Meier and the log-rank test were used. The Cox regression model was used for multivariate analysis of 28-day and long-term mortality. Results: Fifty-two (24%) of the 217 patients who met the study criteria were positive for C. difficile TOX A/B. The crude 28-day and long-term mortality rates of the entire cohort were 12.4% and 56%, respectively. On Cox regression analysis, hypoalbuminaemia, impaired functional capacity, and elevated serum urea levels were found to be the only independent and significant variables associated with long-term mortality. C. difficile toxin positivity per se was not associated with increased short- or long-term mortality rates. Conclusions: Antibiotic-associated diarrhoea is associated with high rates of short- and long term mortality. Hypoalbuminaemia, renal failure, and impaired function capacity predict mortality. C. difficile involvement by itself does not further increase the risk of death in these patients. P765 Co-existence of Clostridium difficile and vancomycin-resistant enterococci in stool samples, in a tertiary hospital in Greece, during a one-year period M. Orfanidou, E. Vagiakou, P. Karabogia, M. Karanika, A. Strouza, H. Malamou-Lada (Athens, GR) Objectives: The surveillance of vancomycin resistant enterococci (VRE) from stool specimens submitted for Clostridium difficile (Cd) testing, in a tertiary Hospital in Athens, Greece, during one year period (6/2005 – 6/2006) Methods: During the study period 553 stool samples from patients with hospital acquired diarrhoea were examined for both Cd and VRE using cycloserine cefoxitin blood agar (BD) and esculin azide agar with 6 mg/L vancomycin (VA), respectively. Cd strains were identified by rapid ANA II (Remel, Lenexa) and latex test (Culturette, BD). VRE strains were identified by VITEK 2 (bioM´erieux). Toxin A was detected from Cd strains by an ELISA (Vidas, bioM´erieux) and a chromatographic assay (ColorPak, BD). Both toxins A&B were detected by an EIA (Premier Toxins A&B, Meridian). Results: Cd strains were isolated in 67/553 (12%) and VRE in 125/553 (22.6%) faecal specimens. Co-existence of Cd and VRE was observed in 17/67 (25.4%) specimens. Toxin A+B+ producers were 9/17, A-B+ 5/17 and A-B− 3/17 Cd strains. These 17 specimens were obtained from patients of Internal Medicine, Gastroenterology, Surgical, Hematology and Nephrology department. The mean age was 66.7 years (range 44−83 years). The underlying diseases were: diabetes mellitus, cancer, Crohn’s disease and operation during the past six months. All of the patients were under antibiotic therapy, mainly with b-lactams and glycopeptides, during their hospitalisation. All of Cd-positive patients were treated with metronidazole (MTZ), with the exception of one
B. Elliott, B. Chang, T. Riley (Perth, AU) Background: Clostridium difficile is an important nosocomial pathogen. Toxigenic strains usually produce toxins A and B, which are primary virulence factors of C. difficile. Some strains produce an additional toxin, an adenosine-diphosphate ribosyltransferase known as binary toxin, the role of which in pathogenicity is unknown. There has been concern about the recent emergence of a hypervirulent fluoroquinolone-resistant strain (PCR ribotype 027) in North America and Europe. Objectives: To determine the circulating molecular types of C. difficile in Australia, and the prevalence of different toxin genotypes including binary-toxin positive strains. The extent of antimicrobial resistance was also investigated. Methods: A total of 115 recent Western Australian (WA) clinical isolates was examined and compared to 34 clinical isolates from the Eastern States (ES) of Australia and a PCR ribotype 027 isolate. PCR was used to detect C. difficile toxin genes and PCR ribotyping to type isolates. Results: Of the WA isolates, 10 of 103 (10%) were toxin A-negative, B-positive while 21 of 103 (20%) were non-toxigenic. Only 1 of 33 (3%) ES isolates was toxin A-negative, B-positive, while 4 of 33 (12%) were non-toxigenic. These differences were not statistically significant. Binary toxin genes were detected in 17 of 103 (17%) WA isolates, but only 3 of 33 (9%) ES isolates. Two toxin A-negative, B-negative strains possessing binary toxin genes were detected in WA. Computer analysis of ribotyping patterns divided 95 Australian isolates into 51 PCR ribotypes. No isolate with a ribotyping pattern matching that of PCR ribotype 027 was found. Little antimicrobial resistance was found in WA C. difficile isolates. Fluoroquinolone resistance was detected in one WA and one ES isolate. Clindamycin resistance was detected in 6 WA isolates (6%). No metronidazole or vancomycin resistance was detected. Conclusions: Clinical isolates of C. difficile in WA are diverse with respect to both their toxin genotype and PCR ribotype. Antimicrobial resistance, including fluoroquinolone resistance, is low in WA, possibly as a reflection of restricted antimicrobial usage. The PCR ribotype 027 strain was not detected. P767 Quantification of Clostridium difficile by real-time PCR in hospital environmental samples C. Nonnenmacher, R. Kropatsch, S. Schumacher, R. Mutters (Marburg, DE) Objective: The aim of this study was to detect and quantify Clostridium difficile in environmental samples obtained in hospital units where Clostridium difficile symptomatic patients were hospitalysed. Methods: A real-time PCR assay was established for the detection and quantification of C. difficile in environmental samples. Quantification was performed with specific 16S rRNA target sequences using double fluorescence labeled probes. 221 samples were collected from environmental sites considered to be commonly exposed to patients and healthcare staff from the hospital settings. Sampling was performed with sterile cotton wool swabs moistened with 0.25% Ringer’s solution. The samples were placed immediately in a Schaedler boullion and incubated under anerobic conditions for 3 days, and subsequently DNA extraction was performed.
17th ECCMID / 25th ICC, Posters patient who presented pseudomembranous colitis and to whom MTZ was given simultaneously with VA. None of the 17 patients presented VRE bacteraemia. Interestingly, 7/67 Cd-positive patients who were treated successfully for their intestinal infection (five with MTZ and two with VA) presented VRE in their stool samples after their treatment. Conclusions: In our hospital co-existence of Cd and VRE is high. This may result in the emergence of vancomycin resistant Cd posing new challenges in the management of hospital associated diarrhoea. So appropriate antibiotic policy and strict enteric precautions should be implemented to break the vicious circle between these two bacteria.
J. Bishara, S. Pitlik, Z. Samra (Petah-Tiqva, IL) P766 Clostridium difficile in Australia Background: Clostridium difficile infection is implicated in 20 to 30% of cases of antibiotic-associated diarrhoea. Previous studies have shown conflicting results relating to mortality attributable to C. difficile infection. The objective of this study was to determine the impact of C. difficile infection on short- and long-term mortality in hospitalised patients with antibiotic-associated diarrhoea. Methods: All patients hospitalised from October 2003 to January 2004 who had antibiotic-associated diarrhoea and underwent stool enzyme immunoassay for C. difficile TOX A/B were followed prospectively. For univariate survival analysis the Kaplan-Meier and the log-rank test were used. The Cox regression model was used for multivariate analysis of 28-day and long-term mortality. Results: Fifty-two (24%) of the 217 patients who met the study criteria were positive for C. difficile TOX A/B. The crude 28-day and long-term mortality rates of the entire cohort were 12.4% and 56%, respectively. On Cox regression analysis, hypoalbuminaemia, impaired functional capacity, and elevated serum urea levels were found to be the only independent and significant variables associated with long-term mortality. C. difficile toxin positivity per se was not associated with increased short- or long-term mortality rates. Conclusions: Antibiotic-associated diarrhoea is associated with high rates of short- and long term mortality. Hypoalbuminaemia, renal failure, and impaired function capacity predict mortality. C. difficile involvement by itself does not further increase the risk of death in these patients. P765 Co-existence of Clostridium difficile and vancomycin-resistant enterococci in stool samples, in a tertiary hospital in Greece, during a one-year period M. Orfanidou, E. Vagiakou, P. Karabogia, M. Karanika, A. Strouza, H. Malamou-Lada (Athens, GR) Objectives: The surveillance of vancomycin resistant enterococci (VRE) from stool specimens submitted for Clostridium difficile (Cd) testing, in a tertiary Hospital in Athens, Greece, during one year period (6/2005 – 6/2006) Methods: During the study period 553 stool samples from patients with hospital acquired diarrhoea were examined for both Cd and VRE using cycloserine cefoxitin blood agar (BD) and esculin azide agar with 6 mg/L vancomycin (VA), respectively. Cd strains were identified by rapid ANA II (Remel, Lenexa) and latex test (Culturette, BD). VRE strains were identified by VITEK 2 (bioM´erieux). Toxin A was detected from Cd strains by an ELISA (Vidas, bioM´erieux) and a chromatographic assay (ColorPak, BD). Both toxins A&B were detected by an EIA (Premier Toxins A&B, Meridian). Results: Cd strains were isolated in 67/553 (12%) and VRE in 125/553 (22.6%) faecal specimens. Co-existence of Cd and VRE was observed in 17/67 (25.4%) specimens. Toxin A+B+ producers were 9/17, A-B+ 5/17 and A-B− 3/17 Cd strains. These 17 specimens were obtained from patients of Internal Medicine, Gastroenterology, Surgical, Hematology and Nephrology department. The mean age was 66.7 years (range 44−83 years). The underlying diseases were: diabetes mellitus, cancer, Crohn’s disease and operation during the past six months. All of the patients were under antibiotic therapy, mainly with b-lactams and glycopeptides, during their hospitalisation. All of Cd-positive patients were treated with metronidazole (MTZ), with the exception of one
B. Elliott, B. Chang, T. Riley (Perth, AU) Background: Clostridium difficile is an important nosocomial pathogen. Toxigenic strains usually produce toxins A and B, which are primary virulence factors of C. difficile. Some strains produce an additional toxin, an adenosine-diphosphate ribosyltransferase known as binary toxin, the role of which in pathogenicity is unknown. There has been concern about the recent emergence of a hypervirulent fluoroquinolone-resistant strain (PCR ribotype 027) in North America and Europe. Objectives: To determine the circulating molecular types of C. difficile in Australia, and the prevalence of different toxin genotypes including binary-toxin positive strains. The extent of antimicrobial resistance was also investigated. Methods: A total of 115 recent Western Australian (WA) clinical isolates was examined and compared to 34 clinical isolates from the Eastern States (ES) of Australia and a PCR ribotype 027 isolate. PCR was used to detect C. difficile toxin genes and PCR ribotyping to type isolates. Results: Of the WA isolates, 10 of 103 (10%) were toxin A-negative, B-positive while 21 of 103 (20%) were non-toxigenic. Only 1 of 33 (3%) ES isolates was toxin A-negative, B-positive, while 4 of 33 (12%) were non-toxigenic. These differences were not statistically significant. Binary toxin genes were detected in 17 of 103 (17%) WA isolates, but only 3 of 33 (9%) ES isolates. Two toxin A-negative, B-negative strains possessing binary toxin genes were detected in WA. Computer analysis of ribotyping patterns divided 95 Australian isolates into 51 PCR ribotypes. No isolate with a ribotyping pattern matching that of PCR ribotype 027 was found. Little antimicrobial resistance was found in WA C. difficile isolates. Fluoroquinolone resistance was detected in one WA and one ES isolate. Clindamycin resistance was detected in 6 WA isolates (6%). No metronidazole or vancomycin resistance was detected. Conclusions: Clinical isolates of C. difficile in WA are diverse with respect to both their toxin genotype and PCR ribotype. Antimicrobial resistance, including fluoroquinolone resistance, is low in WA, possibly as a reflection of restricted antimicrobial usage. The PCR ribotype 027 strain was not detected. P767 Quantification of Clostridium difficile by real-time PCR in hospital environmental samples C. Nonnenmacher, R. Kropatsch, S. Schumacher, R. Mutters (Marburg, DE) Objective: The aim of this study was to detect and quantify Clostridium difficile in environmental samples obtained in hospital units where Clostridium difficile symptomatic patients were hospitalysed. Methods: A real-time PCR assay was established for the detection and quantification of C. difficile in environmental samples. Quantification was performed with specific 16S rRNA target sequences using double fluorescence labeled probes. 221 samples were collected from environmental sites considered to be commonly exposed to patients and healthcare staff from the hospital settings. Sampling was performed with sterile cotton wool swabs moistened with 0.25% Ringer’s solution. The samples were placed immediately in a Schaedler boullion and incubated under anerobic conditions for 3 days, and subsequently DNA extraction was performed.