Epidemiology of community-associated C. difficile

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Keep calm and carry on

The study by Chitnis and colleagues provides valuable insights into the epidemiology of community-associated C. difficile infection.

Patients with community-associated CDI showed a trend for increased use of PPIs among those without antibiotic exposure compared with those who had taken antibiotics (31.2% vs. 25.8%, P = .7). However, this analysis was not adjusted for potential confounders. When all potential predictors of CDI were included in a multivariable analysis, no association between PPI use and CDI was found.

Dr. Grigorios I. Leontiadis

Given the recent publicity on a potential association between PPIs and CDI, the investigators had to refer to PPIs in their conclusions. This study was not designed to prove or disprove the role of PPIs in CDI. We should not be distracted from the solid finding of the study, which is the alarmingly high proportion (82%) of patients with community-associated CDI who were found to have had recent outpatient health care exposure. This study has also shed light on the potential role of household members who are infants or have active CDI.

Until well-designed prospective cohort studies clarify which medications, other than antibiotics, predispose for CDI, we should "keep calm and carry on." All drugs, not only those that are currently associated with CDI, should be used cautiously. Scapegoating will only delay the identification of the real risk factors for this disastrous infection.

Dr. Grigorios I. Leontiadis is in the division of gastroenterology at McMaster University, Hamilton, Ont. He was a consultant to a PPI manufacturer more than 4 years ago.



Among patients with community-associated Clostridium difficile infection, more than a third had not used antibiotics in the 12 weeks before diagnosis and more than half reported limited or no health care contact over the same period.

To assess possible sources of infection, Dr. Amit S. Chitnis and his colleagues at the Centers for Disease Control and Prevention reviewed the medical records of, and interviewed, 984 patients with new-onset community-associated C. difficile infection (CDI).

The patients’ median age was 51 years and median Charlson comorbidity index 0. Almost 90% were white; two-thirds were women; 41% had preceding outpatient care such as surgery or dialysis.

Investigators found that 400 patients (41%) reported low-level health care exposure, such as a visit to a physician or dentist, while 177 (18%) reported no exposure (JAMA Intern. Med. 2013;173:1359-67).

Sixty-four percent (631) reported antibiotic use within 12 weeks of diagnosis, while 28% (273) reported using a PPI, and 9% (90) reported using an H2-receptor antagonist. Among 177 patients with no health care contact, 44% had used antibiotics, 24% used a PPI, and 12% had used H2-receptor antagonists.

Patients with no, or limited, health care contact were significantly more likely to live with an active CDI case or have contact with infants under a year old, who can be asymptomatic CDI carriers. There were no associations between CDI and animal exposure. "Prevention of community-associated CDI should primarily focus on reducing inappropriate antibiotic use and better infection control practices in outpatient settings," the investigators concluded. They suggested evaluating CDI transmission in household settings and reduction of PPI use.

The CDC funded the work. The authors reported no conflicts of interest.

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