community c diff infections

potentially useful study done in Denmark looking at the prevalence of c. difficile infections in community patients seen for unformed stools (see cdiff in community clin microbio 2014​ in dropbox, or doi.org/10.1111/1469-0691.12758#sthash.lfaoG3fB.dpuf). details:

--12174 "unformed stool" samples sent to lab for evaluation for any enteric pathogen by general practitioners were then automatically tested for c. diff
--194 samples (1.5%) were positive for c diff, comparable to incidence of salmonella. they did nested case-control study, with 152 c diff patients compared with 304 age and sex-matched controls and using weighted multi-variable logistic regression
--compared to others with diarrhea, those with c diff had more severe complaints, underlying diseases, antibiotic use, prior hospitalization (none of this particularly surprising)
--but in Denmark, MDs requested c diff testing in only 7% of samples (which detected only 40% of the cases)
--and, if following the Danish recommendations that c diff be checked if patient had prior antibiotic use or hospitalization, only 61% of cases would have been detected.

so, this study confirms some others that found that over 1/3 of community-based c diff infections have no known risk factors!! this study brings up a couple of important issues (assuming the community prevalence of c diff is similar here as in denmark -- a study in the UK for example did not find much c diff in the community):
--c diff prevalence is similar to other enteric pathogens that we test for.  so, we should consider testing for c diff whenever we decide it is appropriate to test for the other pathogens
--c diff offers particular issues which highlight the utility of diagnosing it: recurrence is frequent -- in this study in which 80% of the c diff positive patients had followup, 79% of them received treatment (mostly metronidazole), and 25% had recurrent diarrhea within 6 months with confirmed c diff positive in 37% of them. and 4% were hospitalized, 1% had c diff as contributing cause of death (they did not note whether treatment altered the recurrence rate). by the way, the issue of recurrence in c diff infection is pretty complex and is typically cited in the 25% range. in some studies about 1/2 of recurrent infections are actually reinfection with different c diff strain and not true recurrence. also, the use of antibiotics (metronidazole and/or vanco) alter the gut microbiome dramatically and potentially increase the likelihood of recurrence, esp if a few c diff spores evade the antibiotics, as well as reinfection (which raises question of utility of probiotics???)

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