Kevin C Katz1, George R Golding2, Kelly Baekyung Choi2, Linda Pelude2, Kanchana R Amaratunga2, Monica Taljaard2, Stephanie Alexandre2, Jun Chen Collet2, Ian Davis2, Tim Du2, Gerald A Evans2, Charles Frenette2, Denise Gravel2, Susy Hota2, Pamela Kibsey2, Joanne M Langley2, Bonita E Lee2, Camille Lemieux2, Yves Longtin2, Dominik Mertz2, Lorraine Maze Dit Mieusement2, Jessica Minion2, Dorothy L Moore2, Michael R Mulvey2, Susan Richardson2, Michelle Science2, Andrew E Simor2, Paula Stagg2, Kathryn N Suh2, Geoffrey Taylor2, Alice Wong2, Nisha Thampi2. 1. North York General Hospital (Katz), Toronto, Ont.; National Microbiology Laboratory (Golding, Du, Mulvey), Winnipeg, Man.; Public Health Agency Canada (Choi, Pelude, Amaratunga, Alexandre, Gravel), Ottawa, Ont.; Ottawa Hospital Research Institute (Taljaard), Ottawa, Ont.; BC Children's Hospital, BC Women's Hospital (Collet), Vancouver, BC; Queen Elizabeth II Health Sciences Centre (Davis), Halifax, NS; Kingston General Hospital (Evans), Kingston, Ont.; McGill University Health Centre (Frenette), Montréal, Que.; University Health Network (Hota, Lemieux), Toronto, Ont.; Royal Jubilee Hospital (Kibsey), Victoria, BC; IWK Health Centre (Langley), Halifax, NS; Stollery Children's Hospital (Lee), Edmonton, Alta.; Jewish General Hospital (Longtin), Montréal, Que.; Hamilton Health Sciences (Mertz), Hamilton, Ont.; Mount Sinai Hospital (Maze Dit Mieusement), Toronto, Ont.; Regina General Hospital (Minion), Regina, Sask.; Montreal Children's Hospital (Moore), Montréal, Que.; The Hospital for Sick Children (Richardson, Science), Toronto, Ont.; Sunnybrook Health Sciences Centre (Simor), Toronto, Ont.; Western Memorial Regional Hospital (Stagg), Corner Brook, NL; The Ottawa Hospital (Suh, Amaratunga), Ottawa, Ont.; University of Alberta Hospital (Taylor), Edmonton, Alta., Royal University Hospital (Wong), Saskatoon, Sask.; Children's Hospital of Eastern Ontario (Thampi), Ottawa, Ont. Kevin.Katz@nygh.on.ca. 2. North York General Hospital (Katz), Toronto, Ont.; National Microbiology Laboratory (Golding, Du, Mulvey), Winnipeg, Man.; Public Health Agency Canada (Choi, Pelude, Amaratunga, Alexandre, Gravel), Ottawa, Ont.; Ottawa Hospital Research Institute (Taljaard), Ottawa, Ont.; BC Children's Hospital, BC Women's Hospital (Collet), Vancouver, BC; Queen Elizabeth II Health Sciences Centre (Davis), Halifax, NS; Kingston General Hospital (Evans), Kingston, Ont.; McGill University Health Centre (Frenette), Montréal, Que.; University Health Network (Hota, Lemieux), Toronto, Ont.; Royal Jubilee Hospital (Kibsey), Victoria, BC; IWK Health Centre (Langley), Halifax, NS; Stollery Children's Hospital (Lee), Edmonton, Alta.; Jewish General Hospital (Longtin), Montréal, Que.; Hamilton Health Sciences (Mertz), Hamilton, Ont.; Mount Sinai Hospital (Maze Dit Mieusement), Toronto, Ont.; Regina General Hospital (Minion), Regina, Sask.; Montreal Children's Hospital (Moore), Montréal, Que.; The Hospital for Sick Children (Richardson, Science), Toronto, Ont.; Sunnybrook Health Sciences Centre (Simor), Toronto, Ont.; Western Memorial Regional Hospital (Stagg), Corner Brook, NL; The Ottawa Hospital (Suh, Amaratunga), Ottawa, Ont.; University of Alberta Hospital (Taylor), Edmonton, Alta., Royal University Hospital (Wong), Saskatoon, Sask.; Children's Hospital of Eastern Ontario (Thampi), Ottawa, Ont.
Abstract
BACKGROUND: The clinical and molecular epidemiology of health care-associated Clostridium difficile infection in nonepidemic settings across Canada has evolved since the first report of the virulent North American pulsed-field gel electrophoresis type 1 (NAP1) strain more than 15 years ago. The objective of this national, multicentre study was to describe the evolving epidemiology and molecular characteristics of health care-associated C. difficile infection in Canada during a post-NAP1-epidemic period, particularly patient outcomes associated with the NAP1 strain. METHODS: Adult inpatients with C. difficile infection were prospectively identified, using a standard definition, between 2009 and 2015 through the Canadian Nosocomial Infection Surveillance Program (CNISP), a network of 64 acute care hospitals. Patient demographic characteristics, severity of infection and outcomes were reviewed. Molecular testing was performed on isolates, and strain types were analyzed against outcomes and epidemiologic trends. RESULTS: Over a 7-year period, 20 623 adult patients admitted to hospital with health care-associated C. difficile infection were reported to CNISP, and microbiological data were available for 2690 patients. From 2009 to 2015, the national rate of health care-associated C. difficile infection decreased from 5.9 to 4.3 per 10 000 patient-days. NAP1 remained the dominant strain type, but infection with this strain has significantly decreased over time, followed by an increasing trend of infection with NAP4 and NAP11 strains. The NAP1 strain was significantly associated with a higher rate of death attributable to C. difficile infection compared with non-NAP1 strains (odds ratio 1.91, 95% confidence interval [CI] 1.29-2.82). Isolates were universally susceptible to metronidazole; one was nonsusceptible to vancomycin. The proportion of NAP1 strains within individual centres predicted their rates of health care-associated C. difficile infection; for every 10% increase in the proportion of NAP1 strains, the rate of health care-associated C. difficile infection increased by 3.3% (95% CI 1.7%-4.9%). INTERPRETATION: Rates of health care-associated C. difficile infection have decreased across Canada. In nonepidemic settings, NAP4 has emerged as a common strain type, but NAP1, although decreasing, continues to be the predominant circulating strain and remains significantly associated with higher attributable mortality.
BACKGROUND: The clinical and molecular epidemiology of health care-associated Clostridium difficileinfection in nonepidemic settings across Canada has evolved since the first report of the virulent North American pulsed-field gel electrophoresis type 1 (NAP1) strain more than 15 years ago. The objective of this national, multicentre study was to describe the evolving epidemiology and molecular characteristics of health care-associated C. difficileinfection in Canada during a post-NAP1-epidemic period, particularly patient outcomes associated with the NAP1 strain. METHODS: Adult inpatients with C. difficileinfection were prospectively identified, using a standard definition, between 2009 and 2015 through the Canadian Nosocomial Infection Surveillance Program (CNISP), a network of 64 acute care hospitals. Patient demographic characteristics, severity of infection and outcomes were reviewed. Molecular testing was performed on isolates, and strain types were analyzed against outcomes and epidemiologic trends. RESULTS: Over a 7-year period, 20 623 adult patients admitted to hospital with health care-associated C. difficileinfection were reported to CNISP, and microbiological data were available for 2690 patients. From 2009 to 2015, the national rate of health care-associated C. difficileinfection decreased from 5.9 to 4.3 per 10 000 patient-days. NAP1 remained the dominant strain type, but infection with this strain has significantly decreased over time, followed by an increasing trend of infection with NAP4 and NAP11 strains. The NAP1 strain was significantly associated with a higher rate of death attributable to C. difficileinfection compared with non-NAP1 strains (odds ratio 1.91, 95% confidence interval [CI] 1.29-2.82). Isolates were universally susceptible to metronidazole; one was nonsusceptible to vancomycin. The proportion of NAP1 strains within individual centres predicted their rates of health care-associated C. difficileinfection; for every 10% increase in the proportion of NAP1 strains, the rate of health care-associated C. difficileinfection increased by 3.3% (95% CI 1.7%-4.9%). INTERPRETATION: Rates of health care-associated C. difficileinfection have decreased across Canada. In nonepidemic settings, NAP4 has emerged as a common strain type, but NAP1, although decreasing, continues to be the predominant circulating strain and remains significantly associated with higher attributable mortality.
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