CDI is one of the top ten hospital-acquired infections (HAIs) in European Hospitals1 and is estimated to be three times as deadly as MRSA2, Data released at the 27th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) 2017 demonstrate the impact of CDI on the health service amounts to 10,670 bed days over a year, the equivalent to a fully occupied 30 bed ward, with each CDI case costing approximately £7,500.3
In addition, the study conducted by the Scottish Healthcare Associated Infection Prevention Institute (SHAIPI), reveals that a sixth of patients cured of the initial CDI recur within three months and nearly one third of those have a second recurrence within a year.3 The SHAIPI CDI study investigated the clinical outcomes following hospitalisation of patients with CDI in Scotland and consisted of two analyses; the first analysis aimed to understand the impact of the infection;3 the second investigated clinical outcomes in community associated CDI (CA-CDI) and hospital associated CDI (HA-CDI).4
CDI costs healthcare services approximately €3 billion across Europe each year.5 Recurrence of CDI occurs in up to 25% of patients within 30 days of initial treatment with broad-spectrum antibiotics6, and patients with one recurrence have an estimated 40% risk of a further episode.7 Recurrent CDI is associated with increased mortality rates and longer hospital stays.8 CDI is more common in those taking antibiotics, the elderly, transplant patients, those with underlying diseases and hospital patients.9
Professor Alistair Leanord, Consultant Microbiologist, University of Glasgow, commented, “We have seen large reductions in CDI in the UK over the last decade, however, there has been little change in the rates of recurrence and death as a result of Clostridium difficile infection. This study shows that patients with CDI, whether community or hospital associated, have a doubling of mortality, and a longer length of stay with a significant cost to the NHS. We now have a clearer understanding of the national burden of CDI in terms of recurrences, deaths, cost to the healthcare service and the increasing importance of community acquisition of infection. This will allow us to target future interventions in a more focused, cost effective manner to improve patients’ care.”
The study was undertaken by the universities of Glasgow, Strathclyde and Dundee, and data was analysed from 3,304 hospital cases of CDI and 9,516 controls from August 2010 to July 2013. Of the total number of CDI cases recorded, 58% came from female patients. In terms of mortality, 29% of those with CDI died within two months compared to 14% of control cases and hazard ratio of death was also found to be 2.1 times greater for CDI cases compared to controls (95% 1.9, CI 2.5). With regard to time spent in hospitals, those with CDI had an estimated additional length of stay of 9.7 days compared to controls.3
The second data analysis consisted of 1,297 CA-CDI cases and 3,980 controls and 2,007 HA-CDI cases and 5,536 controls. Results suggest that, compared to controls, mortality rates are higher amongst HA-CDI cases (33.0% vs 17.7%) than in CA-CDI cases (22.4% vs 9.6%). Median length of stay was 7.2 days greater than controls for CA-CDI cases and 12.0 days greater for HA-CDI cases.4
Professor Mark Wilcox, Professor of Medical Microbiology, Leeds Teaching Hospitals and University of Leeds, commented, “These new studies focus on the outcomes associated with CDI, including community- and hospital-associated cases. The findings, based on large groups of cases and control patients, emphasise the considerable healthcare and societal burdens of CDI. Notably there was a doubling risk of death for both community- and hospital-associated CDI cases compared with (non-CDI) control patients.”
He continued, “Furthermore, the lengths of hospital stay for both groups of CDI cases was about twice as long as that for controls; these add up to a substantial burden on the NHS, at a time of major service pressures. The figures mean that we must optimise efforts to prevent CDI and to treat cases optimally to reduce the risk of recurrent infections.”
Reducing the threat and the burden of infectious diseases like CDI is increasingly linked to antibiotic stewardship.10 In this context, inappropriate use of antibiotics may cause the development of antimicrobial resistance,11 increasing risk of CDI and other medical complications.9,11 CDI is also often treated with broad-spectrum antibiotics that further damage the ‘good’ bacteria, increasing the risk of the CDI returning.7,12 Refining and optimising the use of antibiotics in the treatment of CDI therefore has the potential to serve as an accepted practice example for antibiotic stewardship in the treatment of infectious diseases.
References
1. European Centre for Disease Prevention and Control (ECDC). Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals 2011-2012. Stockholm, 2013. Available from: http://ecdc.europa.eu/en/publications/Publications/healthcare-associated-infections-antimicrobial-use-PPS.pdf (last accessed April 2017).
2. European Centre for Disease Prevention and Control/European Medicines Agency (ECDC/EMEA). Joint technical report The bacterial challenge: time to react. Stockholm: ECDC / EMEA; 2009. Available from: http://ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf (last accessed April 2017).
3. Data on file, AI/17/0003/APEL, Astellas Pharma Europe Ltd, April 2017.
4. Data on file, AI/17/0002/APEL, Astellas Pharma Europe Ltd, April 2017.
6. Kuijper EJ, et al. ESCMID study group for Clostridium difficile. Emergence of Clostridium difficile associated disease in North America and Europe. Clin Microbiol Infect. 2006;12:2-18.
7. Johnson S, et al. Vancomycin, Metronidazole, or Tolevamer for Clostridium difficile Infection: Results From Two Multinational, Randomized, Controlled Trials. Clin Infect Dis. 2014;59(3):345–54.
8. Olsen MA, et al. Recurrent Clostridium difficile infection is associated with increased mortality. Clin Microbiol Infect. 2014;1-7.
9. Barbut F, Petit JC. Epidemiology of Clostridium Difficile Associated Infections. Clin Microbiol Infect. 2001;7:405-10.
10. Mamoon A. An evaluation of the impact of antibiotic stewardship on reducing the use of high-risk antibiotics and its effect on the incidence of Clostridium difficile infection in hospital settings. Journal of antimicrobial chemotherapy. 2012:67(12):2988-2996.
11. Bell BG. A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance. BMC Infectious Diseases. 2014;14:13.
12. Louie TJ, et al. Fidaxomicin preserves the intestinal microbiome during and after treatment of Clostridium difficile infection (CDI) and reduces both toxin reexpression and recurrence of CDI. Clinical Infectious Diseases.
