Incidence, outcome, and risk factors for recurrence of nosocomial Clostridioides difficile infection in adults: A prospective cohort study

Background: Nosocomial Clostridioides difficile infection (CDI) complicates up to 1% of all hospital admissions and is associated with considerable health burden. Aims: To determine the incidence and outcomes of nosocomial CDI at a major University Medical Center. Methods: Consecutive adult nosocomial CDI cases were prospectively identified. Stool samples were collected for ribotyping and antibiotic resistance testing. Patients were followed for eight weeks after discharge for relapse. Results: Over a 2-year period, 215 patients developed nosocomial CDI (incidence 2:1000) and 200 (mean age 62.2 ± 19.6 years) gave informed consent. Mean hospital stay was 23.3 ± 28.9 days (range 0–278). Infection was diagnosed within 7 days of admission (range 0–95) in 129 patients (64.5%). More than two-thirds (69.0%) were previously hospitalized within 12 weeks of the index hospitalization. Twenty five percent received prior antibiotics within eight weeks. Fifty-two patients (26.0%) did not receive antibiotics prior to diagnosis. Considerable comorbidities (Charlson Comorbidity Index ≥8) were noted in 33.5% of patients. Recurrence occurred in 43 patients (21.5%). On multivariate logistic regression, fluoroquinolone exposure was the only predictor of recurrence (OR = 2.9, 95%CI 1.1–7.7). Overall mortality was 14.0% and CCI ≥8 was the only predictor on multivariate analysis (p = 0.004). Genotyping did not identify any known hypervirulent strains and all isolates were susceptible to metronidazole and vancomycin. Conclusion: Antibiotic exposure, comorbidities, and prior hospitalization constitute the major risk factors for nosocomial CDI. Recurrence is common and is associated with fluoroquinolones exposure. High baseline comorbidity score was the only predictor of increased mortality in this prospective cohort. Keywords: Clostridium difficile, Clostridioides difficile, Nosocomial, Infection, Relapse, Recurrence, Hospital, Diarrhea, Antibiotics, Genotyping, Epidemiology, Middle East