Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
Eur J Clin Microbiol Infect Dis. 2017 Oct;36(10):1777-1786. doi: 10.1007/s10096-017-2991-y. Epub 2017 May 13.
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.
艰难梭菌感染（CDI）的爆发由 027 型（B1/NAP1）引起，始于 2014 年 11 月我院，并在随后的几个月中产生了 141 例病例。本研究旨在描述这次爆发，评估复发性 CDI-027 的危险因素，并分析一种新的治疗策略的实施情况。这是一项针对所有 CDI-027 患者的前瞻性研究，时间为 2014 年 11 月至 2015 年 11 月。我们每天为每位患者收集流行病学数据。我们比较了 CDI-027 复发患者和未复发患者的临床特征和治疗方法。有趣的是，22%的患者存在肝硬化，且大多数患者接受利福昔明预防肝性脑病。患者还服用了抗生素（93.6%）和质子泵抑制剂（80.1%）。总的来说，27 例（23.5%）患者出现了首次 CDI-027 复发。肝硬化增加了复发的风险（44.4%比 14.8%）。接受延长口服万古霉素疗程治疗的患者比接受常规疗程（口服甲硝唑或 10 天万古霉素）的患者复发率更低（8.6%比 44.7%[p≤0.01]；OR，0.91；95%CI，0.028-0.294），归因死亡率也更低（0%比 7.1%；p=0.058）。我们报告了一次 027 型艰难梭菌的爆发，主要发生在肝硬化患者中。复发性 CDI-027 在这些患者中更为常见。一种新的方法包括高剂量延长万古霉素递减作为一线治疗，同时采取一系列爆发措施，似乎可以减少 CDI-027 的病例数、复发率和归因死亡率。然而，这种方法需要进一步研究。
