title: The emergence of community-onset Clostridium difficile infection in a tertiary hospital in Singapore: a cause for concern.
abstract: Increasing rates of Clostridium difficile infection (CDI) among those without traditional risk factors have been reported mainly in Europe and North America. Here we describe the epidemiology, clinical features and ribotypes of CDI at National University Hospital (NUH), a 1000-bed tertiary care hospital in Singapore, from December 2011 to May 2012. All laboratory-confirmed CDI cases ≥21 years old who gave informed consent were included. Clinical data were collected prospectively and participants underwent an interviewer-administered questionnaire. Cases were classified by healthcare facility exposure and severity according to the SHEA guidelines. Included cases were also subjected to PCR and were classified by ribotype. In total, 66 patients participated in the study, of which 33 (50.0%) were healthcare-facility-associated hospital onset (HCFA-HO). Of the 33 community-onset (CO) cases, 14 (42.4%) were HCFA-CO, 10 (30.3%) were indeterminate and 9 (27.3%) were community-associated (CA). Of the CA cases, a majority (90.9%) had prior exposure to a healthcare facility within the last 12 weeks. Clinical characteristics, exposures and outcomes were not different between HO-CDI and CO-CDI. Diagnosis was delayed in CO-CDI compared with HO-CDI (4 days vs. 1 day; P=0.014). There was no difference in distribution of ribotypes between CO-CDI and HO-CDI, with 053 being most prevalent in both groups. CO-CDI increasingly contributes to the burden of CDI in NUH. This may reflect a trend in other parts of Asia. Healthcare professionals should be aware of the possible role of outpatient healthcare environments to CDI risk and thus extend control measures to outpatient settings.
authors.affiliation: Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore.
authors.forename: X Q
authors.initials: XQ
authors.lastname: Tan
authors.affiliation: Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore.
authors.forename: A J
authors.initials: AJ
authors.lastname: Verrall
authors.affiliation: Department of Laboratory Medicine, National University Health System, Singapore.
authors.forename: R
authors.initials: R
authors.lastname: Jureen
authors.affiliation: Microbiology & Immunology School of Pathology & Laboratory Medicine, The University of Western Australia and Division of Microbiology, Nedlands, Perth, WA, Australia.
authors.forename: T V
authors.initials: TV
authors.lastname: Riley
authors.affiliation: Microbiology & Immunology School of Pathology & Laboratory Medicine, The University of Western Australia and Division of Microbiology, Nedlands, Perth, WA, Australia.
authors.forename: D A
authors.initials: DA
authors.lastname: Collins
authors.affiliation: Department of Laboratory Medicine, National University Health System, Singapore.
authors.forename: R T
authors.initials: RT
authors.lastname: Lin
authors.affiliation: Department of Laboratory Medicine, National University Health System, Singapore.
authors.forename: M N
authors.initials: MN
authors.lastname: Balm
authors.affiliation: Department of Laboratory Medicine, National University Health System, Singapore.
authors.forename: D
authors.initials: D
authors.lastname: Chan
authors.affiliation: Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore. Electronic address: mdcpat@nus.edu.sg.
authors.forename: P A
authors.initials: PA
authors.lastname: Tambyah
mesh_terms: D000328:Adult; D000368:Aged; D016360:Clostridioides difficile / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000453:epidemiology* / Q000382:microbiology; D016000:Cluster Analysis; D017714:Community-Acquired Infections / Q000453:epidemiology* / Q000382:microbiology; D003428:Cross Infection / Q000453:epidemiology / Q000382:microbiology; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D017720:Molecular Epidemiology; D021521:Ribotyping; D012846:Singapore / Q000453:epidemiology; D011795:Surveys and Questionnaires; D062606:Tertiary Care Centers
keywords: Clostridium difficile; Infection control; Ribotyping