Risk of secondary cases of Clostridium difficile infection among household contacts of index cases
Introduction
In many industrialized countries, the incidence of Clostridium difficile infection (CDI) has escalated during the last decade.1, 2, 3 This coincided with the emergence of a toxin-hyper-producing strain (BI/NAP1/027), which seems to be more transmissible than other strains within hospital environments, especially in older patients.4 Albeit CDI is classically a nosocomial disease, the incidence of community-acquired CDI also seems to be increasing, representing between 11% and 28% of the cases.5 Little is known about the risk of secondary cases among household contacts of index cases, whether the index case had acquired CDI at the hospital or in the community. To estimate the risk of secondary cases developing outside hospitals by identifying cases that were related to each other, we conducted a retrospective survey of CDI in a well-defined population of Canada, where the BI/NAP1/027 strain emerged in 2002.
Section snippets
Database of Clostridium difficile infections
We included all patients with CDI diagnosed at the Centre Hospitalier Universitaire de Sherbrooke, in the province of Quebec, Canada, from January 1st 1998 to December 31st 2009, and who lived in the Estrie region (population in 2009: 307,252).2 Most CDI patients were identified through a review of the reports of a positive C. difficile cytotoxicity assay in the computerized hospital database, while a few patients, diagnosed solely by endoscopy or pathology, were identified through reviewing
Results
Table 1 displays the nine clusters that were identified. There were five couples in which both spouses developed CDI within a year of each other and four clusters in which a parent and child developed CDI within the same interval. One of the latter clusters will not be considered further, as it involved an 85-year-old man living with his 60-year-old daughter. All but one of these secondary cases occurred within two months of the index case. During the study period, no secondary cases of CDI
Discussion
This study is the first exploring this component of the epidemiology of CDI. CDI person-to-person transmission in the community has been described in a small number of case-reports9, 10, 11 but this has never been quantified systematically.
Albeit we identified a substantial short-term increase in the relative risk amongst household contacts of CDI patients, this translated into a very modest absolute risk, with attack rates of 4.71 per 1000 for spouses and 5.99 per 1000 for children of index
Financial support
This study was supported by departmental funding.
Study design and manuscript preparation
All authors were involved in data analysis as well as manuscript preparation.
Conflict of interest
Dr Pepin has served on advisory boards for Pfizer, Wyeth, Ortho, Merck, Acambis, Iroko and The Medicines Company. Dr Valiquette has served on advisory boards for Oryx, Iroko, Abbott and Wyeth, and has received compensation to conduct clinical trials involving antibacterials from Genzyme, Wyeth, Pfizer, BioCryst, Trius, Cempra, Optimer and Arpida. M. Gonzales Fuentes has no competing interest to report.
Acknowledgement
None.
References (13)
- et al.
Clostridium difficile ribotype 027, toxinotype III, the Netherlands
Emerg Infect Dis
(2006 May) - et al.
Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity
Can Med Assoc J
(2004 Aug 31) - et al.
An epidemic, toxin gene-variant strain of Clostridium difficile
N Engl J Med
(2005 Dec 8) - et al.
Hospitalizations and deaths associated with Clostridium difficile infection, Finland, 1996-2004
Emerg Infect Dis
(2009 May) - et al.
The changing epidemiology of Clostridium difficile infections
Clin Microbiol Rev
(2010 Jul) Estimation de la population des régions administratives selon le groupe d’âge et le sexe, au 1er juillet des années 1996 à 2010
(2011)
Cited by (28)
Risk Factors for Community-Associated Clostridium difficile Infection in Children
2017, Journal of PediatricsCitation Excerpt :Because we were only able to account for immediate family members with records in the MHS database, additional exposure to other family members and household contacts with CDI may have been missed, thereby underestimating the true impact of household CDI exposure. To help quantify the risk of CDI among household contacts of infected persons, Pepin et al26 studied CDI attack rates among 1562 household contacts of 2222 index cases in a region of Quebec, Canada. They discovered that in the 3 months after CDI diagnosis in the index case, the attack rate for spouses and children was only 4.7 of 1000 and 5.9 of 1000, respectively.
The Epidemiology of Clostridium difficile Infection Inside and Outside Health Care Institutions
2015, Infectious Disease Clinics of North AmericaCitation Excerpt :In addition to outpatient settings, other potential sources of C difficile in the community have been described. Exposure to infants, who are known to have a high rate of C difficile colonization, and household members with active CDI have been reported to be associated with increased risk of CA-CDI.44,58 C difficile has also been isolated from food and animals in several countries; however, its association with CDI in humans has not been shown.
First case of autochthonous Clostridium difficile PCR ribotype 027 detected in Spain
2014, Enfermedades Infecciosas y Microbiologia ClinicaCitation Excerpt :To our knowledge, we report the first autochthonous case of C. difficile infection caused by Cd027 in Spain. The patient had no previous contact with health care institutions in Spain or abroad; therefore, we were unable to track the origin of the strain and we ignore if this patient had contact with people (households, relatives, etc.) from environments where Cd027 is frequent.14 The review of the other 3 episodes shows that Cd027 mainly appears as imported cases.
Clostridium difficile infection: How safe are the household contacts?
2013, American Journal of Infection ControlClostridium difficile exposures, colonization, and the microbiome: Implications for prevention
2018, Infection Control and Hospital Epidemiology