title: The Clostridium difficile problem: a South African tertiary institution's prospective perspective.
abstract: OBJECTIVE
  The aim of this study is to report the incidence of Clostridium difficile-associated disease (CDAD) in a tertiary-care hospital in South Africa and to identify risk factors, assess patient outcomes and determine the impact of the hypervirulent strain of the organism referred to as North American pulsed-field type 1 (NAP1).
  
  
  METHODS
  Adults who presented with diarrhoea over a period of 15 months were prospectively evaluated for CDAD using stool toxin enzyme immunoassay (EIA). Positive specimens were evaluated by PCR. Patient demographics, laboratory parameters and outcomes were analysed.
  
  
  RESULTS
  CDAD was diagnosed in 59 (9.2%) of 643 patients (median age 39 years, IQR 30 - 55). Thirty-four (58%) were female. Recent antibiotic exposure was reported in 39 (66%), 27 (46%) had been hospitalised within 3 months, and 14 (24%) had concomitant inflammatory bowel disease (IBD). Nineteen (32%) had community-acquired CDAD (CA-CDAD). The annual incidence of hospital-acquired CDAD (HA-CDAD) was 8.7 cases/10 000 hospitalisations. Two cases of the hypervirulent strain NAP1 were identified. Seven (12%) patients underwent colectomy (OR 6.83; 95% CI 2.41 - 19.3). On logistic regression, only antibiotic exposure independently predicted for CDAD (OR 2.9; 95% CI 1.6 - 5.1). Three (16%) cases of CA-CDAD reported antibiotic exposure (v. 90% of HA-CDAD, p<0.0001). Twelve (86%) patients had concomitant IBD (p<0.0001 v. HA-CDAD). CA-CDAD was significantly associated with antibiotic exposure (OR 0.04, 95% CI 0.01 - 0.24) and IBD (OR 9.6, 95% CI 1.15 - 79.8).
  
  
  CONCLUSIONS
  The incidence of HA-CDAD in the South African setting is far lower than that reported in the West. While antibiotic use was a major risk factor for HA-CDAD, CA-CDAD was not associated with antibiotic therapy. Concurrent IBD was a predictor of CA-CDAD.
authors.affiliation: Department of Medicine, University of Cape Town, South Africa. naayil@gmail.com
authors.forename: N M
authors.initials: NM
authors.lastname: Rajabally
authors.forename: M
authors.initials: M
authors.lastname: Pentecost
authors.forename: G
authors.initials: G
authors.lastname: Pretorius
authors.forename: A
authors.initials: A
authors.lastname: Whitelaw
authors.forename: M
authors.initials: M
authors.lastname: Mendelson
authors.forename: G
authors.initials: G
authors.lastname: Watermeyer
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000009:adverse effects* / Q000145:classification; D015373:Bacterial Typing Techniques; D016360:Clostridioides difficile / Q000187:drug effects / Q000302:isolation & purification / Q000472:pathogenicity; D015897:Comorbidity; D003967:Diarrhea / Q000209:etiology; D004761:Enterocolitis, Pseudomembranous / Q000150:complications / Q000453:epidemiology / Q000382:microbiology; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D015212:Inflammatory Bowel Diseases / Q000453:epidemiology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D062606:Tertiary Care Centers / Q000706:statistics & numerical data
chemical_list: D000900:Anti-Bacterial Agents