Zainul, Nadiah Hanim
(2016)
Prevalance and molecular epidemiology of clostridium difficile infection in Hospital Universiti Sains Malaysia patients and elderly community subjects in Kelantan.
Masters thesis, Universiti Sains Malaysia.
Abstract
Introduction
An increase in the incidence of Clostridium difficile infection (CDI) in Western countries has
come to prominence over the last 15 years. However awareness and surveillance of CDI in
Asia remained poor with epidemiological data being scanty in Asia and in particular Malaysia.
CDI is commonly associated with nosocomial infections, but community acquired CDI has
been reported with increasing frequency lately. Despite the increase in incidence and severity
of CDI, a recent survey found awareness of CDI being poor, with underestimation of its
contribution to antibiotic-associated disease and recurrence rates.
Objective
We aimed to explore the prevalence and associated risk factors of CDI in hospitalized patients
in HUSM. We also aimed to explore the carriage rate among the elderly in the community in
Kelantan. Finally we aimed to determine the level of awareness of CDI among staff and
students in HUSM.
Methodology
This study is divided into 3 arms. For the hospital arm, it was a prospective cross sectional
study of CDI prevalence among 76 hospitalized patients in HUSM from 1st April 2015 until
30th September 2015.
For the community arm, it was a cross sectional study of C. difficile carrier prevalence among
138 elderlies from the community in Kelantan from July 2015 to September 2015.For both arms, stools were tested for C. difficile antigen and toxin detection using C. DIFF
QUIK CHEK COMPLETE®. The samples were then sent to Western Australia for culture and
PCR for toxin genes and ribotyping for molecular epidemiology.
For the awareness survey, it was a cross sectional study of C. difficile awareness among 154
participants comprised of HUSM staff and students during an awareness campaign for C.
difficile in HUSM on 6th August 2015. Data was obtained thru a self-administered questionnaire
which was based from a previous international internet-based awareness study.
Result
For the hospital arm, 20 samples (26.3%) were positive for C. difficile antigen (CDifAg), 7
samples (9.2%) were positive for C. difficile toxin (CDifToxin) and 19 samples (25%) were
positive from direct culture. Significant ribotype diversity with six distinct ribotype groups
(QX001, UK 017, QX 002, QX 107, QX 117 and QX 463) were identified. Charlson
Comorbidity Index, urea, creatinine, albumin and CRP level, duration of hospitalization, use
of antibiotics, use of chemotherapy, underlying medical illness and fulminant severity were
significantly associated with CDI using Simple Logistic Regression (P-value < 0.25). Further
analysis with Multiple Logistic Regression showed significant association between CDI with
age, duration of hospitalization and use of antibiotics (P-value < 0.05).
For the community arm, 2 samples (1.6%) were positive for both CDifAg and direct culture
while negative for CDifToxin. Ribotying of the 2 samples showed unknown strain. From the
study, it was found that the study population did not have high PPI and antibiotics use which
were known CDI risk factors.
For awareness study arm, there was a low level of awareness on CDI with only 2.6% of 154
respondents able to correctly answer all questions correctly. Ironically a large proportion of the
participants (n = 73; 47.4%) considered C. difficile to be overestimated in their current practise.
There was no significant association between level of awareness on CDI with age, gender and
occupation i.e. being a clinician.
Conclusion
In conclusion, this study demonstrated that the prevalence rate for CDI in hospitalized patients
in HUSM were 26.3% for CDifAg, 9.2% for CDifToxin and 25% for direct culture with 6
distinct ribotype strains; QX001, UK 017, QX 002, QX 107, QX 117 and QX 463 identified.
Independent risk factors for CDI were age, duration of hospitalization and use of antibiotics.
The carrier rate for C. difficile was 1.6% among the elderly in the community with unknown
strain identified from PCR ribotyping. Low usage of PPI and antibiotics were seen in our study
population and could explain the low prevalence rate of CDI in our study population.
Low awareness on CDI was seen among healthcare professionals in HUSM which was also
seen internationally. Therefore CDI being an underdiagnosed and under recognised issue in the
healthcare system is an issue that needs to be addressed by all parties.
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