title: High morbidity and mortality of Clostridium difficile infection and its associations with ribotype 002 in Hong Kong.
abstract: We aim to study the disease burden, risk factors and severity of Clostridium difficile infection (CDI) in Hong Kong.
  
  
  
  We conducted a prospective, case-control study in three acute-care hospitals in Hong Kong. Adult inpatients who developed CDI diarrhoea confirmed by PCR (n = 139) were compared with the non-CDI controls (n = 114). Ribotyping of isolates and antimicrobial susceptibility testing were performed.
  
  
  
  The estimated crude annual incidence of CDI was 23-33/100,000 population, and 133-207/100,000 population among those aged ≥65 years. The mean age of CDI patients was 71.5. Nursing home care, recent hospitalization, antibiotics exposure (adjusted OR 3.0, 95% CI 1.3-7.1) and proton-pump inhibitors use (adjusted OR 2.2, 95% CI 1.2-3.9) were risk factors. Severe CDI occurred in 41.7%. Overall mortality was 16.5% (among severe CDI, 26.5%). The commonest ribotypes were 002 (22.8%), 014 (14.1%), 012 and 046; ribotype 027 was absent. Ribotype 002 was associated with fluoroquinolone resistance and higher mortality (47.6% vs. 12.7%; adjusted HR 2.8, 95% CI 1.1-7.0).
  
  
  
  Our findings show high morbidity and mortality of CDI in the older adults, and identify ribotype 002 as a possible virulent strain causing serious infections in this cohort.
authors.affiliation: State Key Laboratory of Digestive Diseases, Institute of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Sunny H
authors.initials: SH
authors.lastname: Wong
authors.affiliation: Department of Microbiology, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Margaret
authors.initials: M
authors.lastname: Ip
authors.affiliation: Health Protection Agency, Public Health Laboratory Birmingham, Birmingham, United Kingdom; Institute of Microbiology, University of Birmingham, Birmingham, B15 2TT, United Kingdom.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Hawkey
authors.affiliation: Department of Microbiology, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Norman
authors.initials: N
authors.lastname: Lo
authors.affiliation: Health Protection Agency, Public Health Laboratory Birmingham, Birmingham, United Kingdom.
authors.forename: Katie
authors.initials: K
authors.lastname: Hardy
authors.affiliation: Health Protection Agency, Public Health Laboratory Birmingham, Birmingham, United Kingdom.
authors.forename: Susan
authors.initials: S
authors.lastname: Manzoor
authors.affiliation: Alice Ho Miu Ling Nethersole Hospital, Hospital Authority, Hong Kong.
authors.forename: Wyman W M
authors.initials: WW
authors.lastname: Hui
authors.affiliation: Alice Ho Miu Ling Nethersole Hospital, Hospital Authority, Hong Kong.
authors.forename: Kin-Wing
authors.initials: KW
authors.lastname: Choi
authors.affiliation: Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Rity Y K
authors.initials: RY
authors.lastname: Wong
authors.affiliation: Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Irene M H
authors.initials: IM
authors.lastname: Yung
authors.affiliation: Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Catherine S K
authors.initials: CS
authors.lastname: Cheung
authors.affiliation: State Key Laboratory of Digestive Diseases, Institute of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Kelvin L Y
authors.initials: KL
authors.lastname: Lam
authors.affiliation: State Key Laboratory of Digestive Diseases, Institute of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Thomas
authors.initials: T
authors.lastname: Kwong
authors.affiliation: State Key Laboratory of Digestive Diseases, Institute of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong; Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong.
authors.forename: William K K
authors.initials: WK
authors.lastname: Wu
authors.affiliation: State Key Laboratory of Digestive Diseases, Institute of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Siew C
authors.initials: SC
authors.lastname: Ng
authors.affiliation: State Key Laboratory of Digestive Diseases, Institute of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Justin C Y
authors.initials: JC
authors.lastname: Wu
authors.affiliation: State Key Laboratory of Digestive Diseases, Institute of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Joseph J Y
authors.initials: JJ
authors.lastname: Sung
authors.affiliation: Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong. Electronic address: leelsn@cuhk.edu.hk.
authors.forename: Nelson
authors.initials: N
authors.lastname: Lee
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016022:Case-Control Studies; D016360:Clostridioides difficile / Q000145:classification / Q000235:genetics / Q000302:isolation & purification / Q000472:pathogenicity*; D003015:Clostridium Infections / Q000453:epidemiology* / Q000276:immunology / Q000382:microbiology* / Q000401:mortality; D003092:Colitis / Q000188:drug therapy / Q000382:microbiology; D017281:Cost of Illness; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology; D003967:Diarrhea / Q000453:epidemiology / Q000382:microbiology; D005260:Female; D024841:Fluoroquinolones / Q000627:therapeutic use; D006723:Hong Kong / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016133:Polymerase Chain Reaction; D011446:Prospective Studies; D021521:Ribotyping; D012307:Risk Factors; D012720:Severity of Illness Index
chemical_list: D000900:Anti-Bacterial Agents; D024841:Fluoroquinolones
keywords: Antibiotics; Clostridium difficile infection; Colitis; Proton-pump inhibitors; Ribotype