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An outbreak of Clostridium difficile PCR ribotype 027 in Spain: risk factors for recurrence and a novel treatment strategy

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Abstract

An outbreak of Clostridium difficile infection (CDI) caused by ribotype 027 (B1/NAP1) began in our hospital in November 2014, and produced 141 episodes in the following months. The aim of this study is to describe this outbreak, assess risk factors for recurrence of CDI-027 and to analyze the implementation of a novel treatment strategy. This is a prospective study of all patients with CDI-027, from November 2014 to November 2015. The epidemiological data were collected daily for each patient. We compared clinical characteristics and treatment between patients with and without recurrence of CDI-027. Interestingly, liver cirrhosis was present in 22% of the patients, and most of them received prophylaxis for hepatic encephalopathy with rifaximin. Patients were also taking antimicrobial drugs (93.6%) and proton pump inhibitors (80.1%). Overall, 27 (23.5%) patients had a first recurrence of CDI-027. Liver cirrhosis increased the risk of recurrence (44.4% vs 14.8%). Patients treated with a prolonged oral vancomycin regimen vs the conventional regimen (oral metronidazole or 10 days of vancomycin) had fewer recurrences (8.6 versus 44.7% [p ≤ 0.01]; OR, 0.91; 95% CI, 0.028–0.294) and less attributable mortality (0% versus 7.1%; p = 0.058). We report an outbreak of CDI-027, mainly in patients with liver cirrhosis. Recurrence of CDI-027 was more common in those patients. A novel approach involving high-dose prolonged vancomycin taper as a first-line treatment, together with a bundle of outbreak measures, seemed to reduce the number of cases of CDI-027, recurrences, and attributable mortality. Nevertheless, this approach warrants further investigation.

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Acknowledgements

We would like to thanks Thomas O’Boyle for his help in the preparation of the manuscript.

The preliminary results of this paper were presented at 26th European Congress of Clinical Microbiology and Infectious Diseases that was held in Amsterdam on April 2016.

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Authors and Affiliations

  1. Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain

    E. Bouza, L. Alcalá, M. Marín, M. Valerio, E. Reigadas, P. Muñoz, M. González-Del Vecchio & V. de Egea

  2. Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain

    E. Bouza, M. Marín & P. Muñoz

  3. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain

    E. Bouza, L. Alcalá, M. Marín, M. Valerio, E. Reigadas, P. Muñoz, M. González-Del Vecchio & V. de Egea

  4. CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain

    E. Bouza, M. Marín & P. Muñoz

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  1. E. Bouza
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  2. L. Alcalá
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  7. M. González-Del Vecchio
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Correspondence to E. Bouza or V. de Egea.

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Funding

This work was partially supported by Fondo de Investigaciones Sanitarias (FIS), Research Project number PI13/00687, Carlos III Health Institute. Co-funded by the European Regional Development Fund (FEDER) “A way of making Europe”.

Conflicts of interests

The authors declare no conflicts of interest.

Ethical approval

This study was approved by the Ethics Committee of Hospital General Universitario Gregorio Marañón.

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Bouza, E., Alcalá, L., Marín, M. et al. An outbreak of Clostridium difficile PCR ribotype 027 in Spain: risk factors for recurrence and a novel treatment strategy. Eur J Clin Microbiol Infect Dis 36, 1777–1786 (2017). https://doi.org/10.1007/s10096-017-2991-y

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