Predictores de riesgo para desarrollo de infección por Clostridium difficile
Palabras clave:
CLOSTRIDIUM DIFFICILE, FACTORES DE RIESGO
Resumen
Clostridium diffícile (CD) es el agente responsable de la mayoría de los episodios de diarrea de origen nosocomial. El objetivo de este estudio fue identificar los factores de riesgo asociados a la infección por C. difficile (ICD) en los pacientes con diarrea de origen nosocomial en el Hospital Universitario Dr. Manuel Quintela. Para ello se llevó adelante un estudio observacional, analítico, de casos y controles no pareados. Se incluyeron todos los pacientes mayores de 18 años que instalaron diarrea posterior a las 72 horas del ingreso al hospital y en quienes se solicitó investigación de CD durante el período abril a diciembre de 2013. Veintisiete pacientes (18,6%) cumplieron con la definición de caso, 105 (72,4%) cumplieron con la definición de control y 13 (9,0%) se excluyeron por presentar solo la prueba de glutamato deshidrogenasa (GDH) positiva. En relación con la presentación clínica, se destaca la asociación significativa de la ICD con la presencia de fiebre. En el análisis univariado el haber recibido antibióticos por más de 30 días y el uso previo de clindamicina estuvieron significativamente asociados a ICD. En el análisis multivariante solo el uso previo de clindamicina (p = 0,004 OR 5,881; IC95% 1,743-19,841) se mantuvo como factor de riesgo independiente. Este hallazgo pone en evidencia que en situación de endemia la implementación de una política de uso racional de clindamicina es una de las medidas necesarias para disminuir la frecuencia de ICD.
Citas
(1) Kuijper EJ, Coignard B, Tüll P; ESCMID Study Group for Clostridium difficile; EU Member States; European Centre for Disease Prevention and Control. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2006; 12(Suppl 6):2-18.
(2) Bartlett JG. Antibiotic-associated diarrhea. Clin Infect Dis 1992; 15(4):573-81.
(3) Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults?: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31(5):431-55.
(4) Uruguay. Ministerio de Salud Pública. Infecciones por Clostridium difficile en hospitales centinela. Uruguay 2012. Disponible en: http://www.msp.gub.uy/sites/default/files/Informe_ICD_2012.pdf
Consulta: 20 noviembre 2015.
(5) Kyne L, Hamel MB, Polavaran R, Kelly CP. Health care costs and mortality associated with nosocomial diarrea due to Clostridium difficile. Clin Infec Dis 2002; 34(3):346-53.
(6) Forster AJ, Taljaard M, Oake N, Wilson K, Roth V, van Walraven C. The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital. CMAJ 2012; 184(1):37-42.
(7) Polk RE, Fox C, Mahoney A, Letcavage J, MacDougall C. Measurement of adult antibacterial drug use in 130 US hospitals: comparison of defined daily dose and days of therapy. Clin Infect Dis 2007; 44(5):664-70.
(8) Garey KW, Graham G, Gerard L, Dao T, Jiang ZD, Price M, et al. Prevalence of diarrhea at a university hospital and association with modifiable risk factors. Ann Pharmacother 2006; 40(6):1030-4.
(9) Garey KW, Asha NJ, Tompkins D, Wilcox MH. Comparative analysis of prevalence, risk factors, and molecular epidemiology of antibiotic-associated diarrhea due to Clostridium difficile, Clostridium perfringens, and Staphylococcus aureus. J Clin Microbiol 2006; 44(8):2785-91.
(10) Heimesaat MM, Granzow K, Leidinger H, Liesenfeld O. Prevalence of Clostridium difficile toxins A and B and Clostridium perfringens enterotoxin A in stool samples of patients with antibiotic-associated diarrhea. Infection 2005; 33(5-6): 340-4.
(11) Beaulieu C, Dionne LL, Julien AS, Longtin Y. Clinical characteristics and outcome of patients with Clostridium difficile infection diagnosed by PCR versus a three-step algorithm. Clin Microbiol Infect 2014; 20(10):1067-73.
(12) Siti Asma H, Norlela O, Fauziahs MI, Zaidah AR, Nurahan M, Rosliza AR, Chan GT, et al. Prevalence of Clostridium difficile toxin in diarhoeal stool samples of patients from a tertiary hospital in North Eastern Penisular Malaysia. Med J Malasya 2012; 67(4):402-5.
(13) Lai CC, Lin SH, Tan CK, Liao CH, Huang YT, Hsueh PR. Clinical manifestations of Clostridium difficile infection in a medical center in Taiwan. J Microbiol Immunol Infect 2014; 47(6):491-6.
(14) Zumbado Salas R, Gamboa Coronado M, Rodríguez Cavallini E, Chaves Olarte E. Clostridium difficile in adult patients with nosocomial diarrhea in a Costa Rican hospital. Am J Trop Med Hyg 2008; 79(2):164-5.
(15) Balsamo A, Paciel D, Palacio R, Hernández N, Moreira M, Datti J, et al. Brote de Clostridium difficile en Hospital de Clínicas: descripción, manejo y control. En: XVII Congreso Panamericano de Infectología: API 2015. Quito, Ecuador 15-19 de mayo de 2015.
(16) Grille P, Olano E, Bertullo H, Bagnulo H. Estudio sobre diarrea en una unidad de cuidados intensivos quirúrgica. Rev Méd Urug 2006; 22(2):136-42.
(17) Polage CR, Solnick JV, Cohen SH. Nosocomial diarrea: evaluation and treatment of causes other than Clostridium difficile. Clin Infect Dis 2012; 55(7):982-9.
(18) Becerra MG, Ospina S, Atehortúa SL, Berbesi DY. Factores de riesgo para la infección por Clostridium difficile. Infectio 2011; 15(4):220-26.
(19) Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D, et al. Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. Am J Gastroenterol 2003; 98(6):1309-14.
(20) Wren MW, Kinson R, Sivapalan M, Schemko M, Shetty NR. Detection of Clostridium difficile infection: a suggested laboratory diagnostic algorithm. Br J Biomed Sci 2009; 66(4):175-9.
(21) El Feghaly RE, Stauber JL, Deych E, Gonzalez C, Tarr PI, Haslam DB. Markers of intestinal inflammation, not bacterial burden, correlate with clinical outcomes in Clostridium difficile infection. Clin Infect Dis 2013; 56(12):1713-21.
(22) Bartlett JG. Narrative review: The new epidemic of Clostridium difficile-associated enteric disease. Ann Intern Med 2006; 145(10):758-64.
(23) Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative Antibiotic Exposures Over Time and the Risk of Clostridium difficile Infection. Clin Infect Dis 2011; 53(1):42-8.
(24) Pepin J, Saheb N, Coulombe MA, Alary ME, Corriveau MP, Autier S, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 2005; 41(9):1254-60.
(25) Owens RC, Donskey CJ, Gaynes RP, Loo VG, Muto CA. Antimicrobial-associated risk factors for Clostridium difficile Infection. Clin Infect Dis 2008; 46(Suppl 1):S19-31.
(26) Slimings C, Riley TV. Antibiotics and hospital-acquired Clostridium difficile infection: update of systematic review and meta-analysis. J Antimicrob Chemother 2014; 69(4):881-91.
(27) Vesta KM, Wells PS, Gentry CA, Stipek WJ. Specific risk factors for Clostridium difficile-associated diarrhea: a prospective, multicenter, case control evaluation. Am J Infect Control 2005; 33(8):469-72.
(28) Hensgens MPM, Goorhuis A, Dekkers OM, Kuijper ED. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother 2012; 67(3):742-8.
(29) Vignoli R, Calvelo E, Cordeiro NF, Lucero R, Ingold E, Quintana A, et al. Association of broad-spectrum antibiotic use with faecal carriage of oxyiminocephalosporin-resistant Enterobacteriaceae in an intensive care unit. J Hosp Infect 2006; 63(3):306–15.
(30) Medina J, Formento C, Pontet J, Curbelo A, Bazet C, Gérez J, et al. Prospective study of risk factors for ventilator-associated pneumonia caused by Acinetobacter species. J Crit Care 2007; 22(1):18-26.
(31) Medina Presentado JC, Paciel López D, Berro Castiglione M, Gérez J. Ceftriaxone and ciprofloxacin restriction in an intensive care unit: less incidence of Acinetobacter spp. and improved susceptibility of Pseudomonas aeruginosa. Rev Panam Salud Pública 2011; 30(6):603-9.
(32) Seija V, Pontet J, Soca A, Gabrielli A, Arregui P, Noveri S, Bentancourt S. Impacto de la restricción de ceftriaxona sobre la ecología bacteriana de una unidad de cuidado intensivo. En: VIII Congreso Panamericano de Medicina Crítica y Terapia Intensiva. Punta del Este, Uruguay 18-21 de noviembre de 2007.
(33) Vardakas KZ, Konstantelias AA, Loizidis Rafailidis PI, Falagas ME. Risk factors for development of Clostridium difficile infection due to BI/NAP1/027 strain: a meta-analysis. Int J Infect Dis 2012; 16(11):e768-73.
(34) Association for Professionals in Infection Control and Epidemiology. Guide to preventing Clostridium difficile infections. Washington, DC: APIC, 2013. Disponible en: http://apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d1-9325-e8be75d86888/File/2013 CDiffFinal.pdf. Consulta: 20 noviembre 2015.
(35) Pear SM, Williamson TH, Bettin KM, Gerding DN, Galgiani JN. Decrease in nosocomial Clostridium difficile–associated diarrhea by restricting clindamycin use. Ann Intern Med 1994; 120(4):272–7.
(36) Climo MW, Israel DS, Wong ES, Williams D, Coudron P, Markowitz SM. Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost. Ann Intern Med. 1998; 128(12 Pt 1):989-95.
(37) Muto CA, Blank MK, Marsh JW, Vergis EN, O’Leary MM, Shutt KA, et al. Control of an outbreak of infection with the hypervirulent Clostridium difficile BI strain in a university hospital using a comprehensive “bundle” approach. Clin Infect Dis 2007; 45(10):1266-73.
(38) Valiquette L, Cossette B, Garant MP, Diab H, Pépin J. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007; 45(Suppl 2):S112-21.
(2) Bartlett JG. Antibiotic-associated diarrhea. Clin Infect Dis 1992; 15(4):573-81.
(3) Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults?: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31(5):431-55.
(4) Uruguay. Ministerio de Salud Pública. Infecciones por Clostridium difficile en hospitales centinela. Uruguay 2012. Disponible en: http://www.msp.gub.uy/sites/default/files/Informe_ICD_2012.pdf
Consulta: 20 noviembre 2015.
(5) Kyne L, Hamel MB, Polavaran R, Kelly CP. Health care costs and mortality associated with nosocomial diarrea due to Clostridium difficile. Clin Infec Dis 2002; 34(3):346-53.
(6) Forster AJ, Taljaard M, Oake N, Wilson K, Roth V, van Walraven C. The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital. CMAJ 2012; 184(1):37-42.
(7) Polk RE, Fox C, Mahoney A, Letcavage J, MacDougall C. Measurement of adult antibacterial drug use in 130 US hospitals: comparison of defined daily dose and days of therapy. Clin Infect Dis 2007; 44(5):664-70.
(8) Garey KW, Graham G, Gerard L, Dao T, Jiang ZD, Price M, et al. Prevalence of diarrhea at a university hospital and association with modifiable risk factors. Ann Pharmacother 2006; 40(6):1030-4.
(9) Garey KW, Asha NJ, Tompkins D, Wilcox MH. Comparative analysis of prevalence, risk factors, and molecular epidemiology of antibiotic-associated diarrhea due to Clostridium difficile, Clostridium perfringens, and Staphylococcus aureus. J Clin Microbiol 2006; 44(8):2785-91.
(10) Heimesaat MM, Granzow K, Leidinger H, Liesenfeld O. Prevalence of Clostridium difficile toxins A and B and Clostridium perfringens enterotoxin A in stool samples of patients with antibiotic-associated diarrhea. Infection 2005; 33(5-6): 340-4.
(11) Beaulieu C, Dionne LL, Julien AS, Longtin Y. Clinical characteristics and outcome of patients with Clostridium difficile infection diagnosed by PCR versus a three-step algorithm. Clin Microbiol Infect 2014; 20(10):1067-73.
(12) Siti Asma H, Norlela O, Fauziahs MI, Zaidah AR, Nurahan M, Rosliza AR, Chan GT, et al. Prevalence of Clostridium difficile toxin in diarhoeal stool samples of patients from a tertiary hospital in North Eastern Penisular Malaysia. Med J Malasya 2012; 67(4):402-5.
(13) Lai CC, Lin SH, Tan CK, Liao CH, Huang YT, Hsueh PR. Clinical manifestations of Clostridium difficile infection in a medical center in Taiwan. J Microbiol Immunol Infect 2014; 47(6):491-6.
(14) Zumbado Salas R, Gamboa Coronado M, Rodríguez Cavallini E, Chaves Olarte E. Clostridium difficile in adult patients with nosocomial diarrhea in a Costa Rican hospital. Am J Trop Med Hyg 2008; 79(2):164-5.
(15) Balsamo A, Paciel D, Palacio R, Hernández N, Moreira M, Datti J, et al. Brote de Clostridium difficile en Hospital de Clínicas: descripción, manejo y control. En: XVII Congreso Panamericano de Infectología: API 2015. Quito, Ecuador 15-19 de mayo de 2015.
(16) Grille P, Olano E, Bertullo H, Bagnulo H. Estudio sobre diarrea en una unidad de cuidados intensivos quirúrgica. Rev Méd Urug 2006; 22(2):136-42.
(17) Polage CR, Solnick JV, Cohen SH. Nosocomial diarrea: evaluation and treatment of causes other than Clostridium difficile. Clin Infect Dis 2012; 55(7):982-9.
(18) Becerra MG, Ospina S, Atehortúa SL, Berbesi DY. Factores de riesgo para la infección por Clostridium difficile. Infectio 2011; 15(4):220-26.
(19) Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D, et al. Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. Am J Gastroenterol 2003; 98(6):1309-14.
(20) Wren MW, Kinson R, Sivapalan M, Schemko M, Shetty NR. Detection of Clostridium difficile infection: a suggested laboratory diagnostic algorithm. Br J Biomed Sci 2009; 66(4):175-9.
(21) El Feghaly RE, Stauber JL, Deych E, Gonzalez C, Tarr PI, Haslam DB. Markers of intestinal inflammation, not bacterial burden, correlate with clinical outcomes in Clostridium difficile infection. Clin Infect Dis 2013; 56(12):1713-21.
(22) Bartlett JG. Narrative review: The new epidemic of Clostridium difficile-associated enteric disease. Ann Intern Med 2006; 145(10):758-64.
(23) Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative Antibiotic Exposures Over Time and the Risk of Clostridium difficile Infection. Clin Infect Dis 2011; 53(1):42-8.
(24) Pepin J, Saheb N, Coulombe MA, Alary ME, Corriveau MP, Autier S, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 2005; 41(9):1254-60.
(25) Owens RC, Donskey CJ, Gaynes RP, Loo VG, Muto CA. Antimicrobial-associated risk factors for Clostridium difficile Infection. Clin Infect Dis 2008; 46(Suppl 1):S19-31.
(26) Slimings C, Riley TV. Antibiotics and hospital-acquired Clostridium difficile infection: update of systematic review and meta-analysis. J Antimicrob Chemother 2014; 69(4):881-91.
(27) Vesta KM, Wells PS, Gentry CA, Stipek WJ. Specific risk factors for Clostridium difficile-associated diarrhea: a prospective, multicenter, case control evaluation. Am J Infect Control 2005; 33(8):469-72.
(28) Hensgens MPM, Goorhuis A, Dekkers OM, Kuijper ED. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother 2012; 67(3):742-8.
(29) Vignoli R, Calvelo E, Cordeiro NF, Lucero R, Ingold E, Quintana A, et al. Association of broad-spectrum antibiotic use with faecal carriage of oxyiminocephalosporin-resistant Enterobacteriaceae in an intensive care unit. J Hosp Infect 2006; 63(3):306–15.
(30) Medina J, Formento C, Pontet J, Curbelo A, Bazet C, Gérez J, et al. Prospective study of risk factors for ventilator-associated pneumonia caused by Acinetobacter species. J Crit Care 2007; 22(1):18-26.
(31) Medina Presentado JC, Paciel López D, Berro Castiglione M, Gérez J. Ceftriaxone and ciprofloxacin restriction in an intensive care unit: less incidence of Acinetobacter spp. and improved susceptibility of Pseudomonas aeruginosa. Rev Panam Salud Pública 2011; 30(6):603-9.
(32) Seija V, Pontet J, Soca A, Gabrielli A, Arregui P, Noveri S, Bentancourt S. Impacto de la restricción de ceftriaxona sobre la ecología bacteriana de una unidad de cuidado intensivo. En: VIII Congreso Panamericano de Medicina Crítica y Terapia Intensiva. Punta del Este, Uruguay 18-21 de noviembre de 2007.
(33) Vardakas KZ, Konstantelias AA, Loizidis Rafailidis PI, Falagas ME. Risk factors for development of Clostridium difficile infection due to BI/NAP1/027 strain: a meta-analysis. Int J Infect Dis 2012; 16(11):e768-73.
(34) Association for Professionals in Infection Control and Epidemiology. Guide to preventing Clostridium difficile infections. Washington, DC: APIC, 2013. Disponible en: http://apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d1-9325-e8be75d86888/File/2013 CDiffFinal.pdf. Consulta: 20 noviembre 2015.
(35) Pear SM, Williamson TH, Bettin KM, Gerding DN, Galgiani JN. Decrease in nosocomial Clostridium difficile–associated diarrhea by restricting clindamycin use. Ann Intern Med 1994; 120(4):272–7.
(36) Climo MW, Israel DS, Wong ES, Williams D, Coudron P, Markowitz SM. Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost. Ann Intern Med. 1998; 128(12 Pt 1):989-95.
(37) Muto CA, Blank MK, Marsh JW, Vergis EN, O’Leary MM, Shutt KA, et al. Control of an outbreak of infection with the hypervirulent Clostridium difficile BI strain in a university hospital using a comprehensive “bundle” approach. Clin Infect Dis 2007; 45(10):1266-73.
(38) Valiquette L, Cossette B, Garant MP, Diab H, Pépin J. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007; 45(Suppl 2):S112-21.
Publicado
2016-09-30
Cómo citar
1.
Menéndez M, Batista N, Bálsamo A, Seija V. Predictores de riesgo para desarrollo de infección por Clostridium difficile. Rev. Méd. Urug. [Internet]. 30 de septiembre de 2016 [citado 26 de noviembre de 2024];32(3):159-65. Disponible en: http://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/164
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