The impact of toxigenic Clostridium difficile colonization (tCDC) in hospitalized patients is not clear.
A prospective study in the medical wards of a regional hospital was performed from January to June 2011. Fecal samples collected from patients at the time of admission were tested for tcdB by real-time polymerase chain reaction (PCR) and cultured for C. difficile. The patients were followed up weekly or when they developed diarrhea during hospitalization. If C. difficile was isolated, tcdA and tcdB would be tested by multiplex PCR. The primary outcome was the development of C. difficile-associated diarrhea (CDAD).
Of 168 patients enrolled, females predominated (87, 51.8%), and the mean patient age was 75.4 years old. Approximately 70% of the patients were nursing home residents, and one third had a recent hospitalization within the prior three months. Twenty-eight (16.7%) patients had tCDC, including 16 (9.5%) patients with tCDC at the time of admission and 12 (7.2%) with tCDC during the follow-up period. With regard to the medications taken during hospitalization, the patients were more likely to have tCDC if they had received more than one class of antibiotics than if they had received monotherapy (odds ratio [OR] 6.67, 95% confidence interval [CI] 1.41–31.56, P = 0.01), particularly if they received a glycopeptide in combination with a cephalosporin or penicillin or a cephalosporin and a carbapenem. More patients with tCDC developed CDAD than those without tCDC (17.9%, 5/28 vs. 1.4%, 2/140, P = 0.002). Overall 7 (4.2%) of the 168 patients developed CDAD, and crude mortality rate of those with and without tCDC was similar (21.4%, 6/28 vs. 19.4%, 27/140, P = 0.79).
Citation: Hung Y-P, Tsai P-J, Hung K-H, Liu H-C, Lee C-I, Lin H-J, et al. (2012) Impact of Toxigenic Clostridium difficile Colonization and Infection among Hospitalized Adults at a District Hospital in Southern Taiwan. PLoS ONE 7(8): e42415. https://doi.org/10.1371/journal.pone.0042415
Editor: Markus M. Heimesaat, Charité, Campus Benjamin Franklin, Germany
Received: April 24, 2012; Accepted: July 5, 2012; Published: August 2, 2012
Copyright: © Hung et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by the grants from the National Science Council, Taiwan (NSC 99–2628-B-006–014-MY3) and Department of Health, Executive Yuan, Taiwan (DOH100-TD-B-111–002) for the consumables in the real-time PCR and multiplex PCR. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Clostridium difficile is a major cause of nosocomial antibiotic-associated diarrhea, with clinical features ranging from mild diarrhea to pseudomembranous colitis or toxic megacolon and even death. A large-scale outbreak involving a hypervirulent C. difficile strain, B1/NAP-1/027, occurred in Quebec, Canada, in 2003 . The incidence of C. difficile infections increased thereafter worldwide, and the trend was accompanied by a substantial increase in the disease severity and mortality rate of C. difficile infections. The pathogenicity of C. difficile is mediated by at least two exotoxins, toxins A and B, and both damage the human colonic mucosa. The toxins are transcribed from tcdA (toxin A) and tcdB (toxin B). The outbreak in Quebec was associated with the increased production of toxins A and B in the causative C. difficile strain. C. difficile infection has been increasingly recognized in Taiwan in recent years, particularly among patients in intensive care units . The dissemination of a predominant C. difficile clone has been noted in southern and northern Taiwan .
Previous investigators reported that approximately two thirds of patients with fecal C. difficile colonization will have persistent colonization during follow up , . The prevalence of C. difficile colonization was estimated to be 4.4–14% at the time of admission to acute care wards and 4.6–20.4% for chronic care wards , , , , , , , . However, the epidemiology of C. difficile colonization in the Asian population was lacking. In an earlier study, 15% of patients without initial C. difficile colonization acquired C. difficile during follow up . However, the incidence of asymptomatic C. difficile carriage in long-term care facility residents was up to 51% . The relationship between prior fecal C. difficile colonization and C. difficile-associated diarrhea (CDAD) remains undefined. One study demonstrated that C. difficile colonization was an independent risk factor for CDAD , but in another study, asymptomatic C. difficile colonization was associated with a decreased risk of CDAD . However, the colonizing C. difficile isolates in feces were not clearly identified as toxigenic or nontoxigenic in those studies, particularly in adult Asian patients. Therefore, the relationship between toxigenic C. difficile colonization (tCDC) and subsequent CDAD remains controversial.
In previous studies, colonization by toxigenic C. difficile strains was studied using cultures and cytotoxin neutralization assays, which were time consuming and technique dependent . Real-time polymerase chain reaction (PCR) to detect the C. difficile toxin B gene (tcdB) has a high sensitivity and specificity for detecting the presence of toxigenic C. difficile isolates , . Utilizing real-time PCR, we attempted to study the epidemiology, risk factors, and clinical impact of fecal colonization by toxigenic C. difficile isolates and subsequent CDAD in hospitalized adults.
Materials and Methods
A prospective study was conducted in the medical wards of the Tainan Hospital, Department of Health, Executive Yuan, a district hospital in southern Taiwan, from January 2011 to June 2011. The study was approved by the institutional review board of Tainan Hospital, Department of Health, Executive Yuan, and written informed consent was obtained from all patients. The inclusion criteria for eligible patients included individuals aged at least 18 years old who were admitted to the medical wards with a hospital stay of at least 5 days. The exclusion criteria were as follows: patients with a history of C. difficile colonization or infection in three months prior to admission; metronidazole or vancomycin therapy within three months of admission; a clinical diagnosis of CDAD at the time of admission; a history of colectomy.
Diarrhea is defined as a change in bowel habits with more than three unformed bowel movements per day for at least 2 days. Information regarding patient status prior to admission, including comorbid conditions or a history of C. difficile colonization or infection, was obtained through oral histories. In addition, medications that may predispose patients to a CDI, such as antibiotics or proton-pump inhibitors (PPIs), that were used for at least one day in three months prior to admission were recorded. The epidemiological analysis was based on the first admission of each patient. All prescribed antibacterial agents were recorded by category. The cephalosporin category included the first- (cefazolin), second- (cefuroxime), third- (ceftriaxone, cefotaxime, and ceftazidime), and fourth-generation (cefepime) cephalosporins. Penicillin derivatives (penicillin, oxacillin, and piperacillin) and the combination of a penicillin derivative and a beta-lactamase inhibitor (amoxicillin-clavulanic acid, ampicillin-sulbactam, and piperacillin-tazobactam) were grouped into the penicillin category. The carbapenem category included imipenem-cilastatin, meropenem, and ertapenem, and the glycopeptide category included vancomycin and teicoplanin.
Fecal samples collected at less than 48 hours after admission and every 7 days during hospitalization were tested by the real-time PCR assay BD GeneOhm™ Cdiff (BD Diagnostics, San Diego, CA), which was kindly offered by the manufacturer, to detect the tcdB gene and were cultured for C. difficile. Stool samples were collected and transported to the laboratory within 6 hours after collection. Stool was frozen below 4°C before processing. The stool culture procedures for C. difficile were as follows. Stool samples were treated with an equal volume of absolute alcohol, homogenized by a vortex mixer, inoculated onto a CCFA (cefoxitin cycloserine fructose agar) plate within 1 hour after collection, and incubated anaerobically for 48 hours in the microbiology laboratory at the Tainan Hospital. If C. difficile was isolated, tcdA, tcdB or 16 S rDNA would be tested for using multiplex PCR, as described previously . Ribotyping was performed for the available C. difficile isolates to detect ribotype 027. The DNA sequences of the PCR-ribotyping primers were 5′-GTGCGGCTGGATCACCTCCT-3′ (corresponding to bases 1482 to 1501 of the 16 S rRNA gene) and 5′-CCCTGCACCCTTAATAACTTGACC-3′ (bases 1 to 24 of 23 S the rRNA gene) , . If the patients developed diarrhea during hospitalization, real-time PCR and stool cultures of fresh fecal samples were repeated.
A case of tCDC was defined as an asymptomatic individual with tcdB detected in a fecal sample by real-time PCR, and CDAD was defined as a symptomatic patient with diarrhea and tcdB detected in a fecal sample. All patients included in the study were followed up until discharge or death. The primary outcome was the development of CDAD in patients with or without tCDC. The secondary outcomes were the crude mortality rate at 30 days and the hospital stay duration.
Statistical analyses were performed using statistical software (SPSS, version 13.0). Continuous data were expressed as the mean ± standard deviation. For analyses between patients with and without tCDC, the χ2 test or Fisher’s test was used for categorical variables, and Student’s t-test was used for continuous variables. A two-tailed P value of less than 0.05 was considered to be statistically significant.
During the 6-month study period, a total of 192 patients were eligible for the study, and 24 patients with no stool available during the first 48 hours after admission were excluded. Thus, 168 patients were enrolled in the study. A total of 254 stool samples were available from 168 patients for testing by real-time PCR and stool cultures. Twenty-six (10.2%) samples grew tcdA+/tcdB+ C. difficile isolates, and all yielded a positive real-time PCR result. In 10 (3.9%) fecal samples, no C. difficile growth was observed, but a positive real-time PCR result was noted. Negative findings of both tests were present in 207 (81.5%) samples. Of note, 11 (4.3%) stool samples grew non-toxigenic C. difficile isolates and were negative by real-time PCR. Among 37 C. difficile isolates, none belonged to ribotype 027.
Eighty-one (48.2%) of the 168 patients were male. The mean patient age was 75.4 years, and 117 (69.6%) patients were nursing home residents. The current use of nasogastric tube feeding was noted in 92 (54.8%) patients. Within 3 months prior to admission, recent hospitalization was noted in 56 (33.3%) patients, 59 (35.1%) had been treated with antibiotics, and 15 (8.9%) had been treated with PPIs. The common underlying diseases included hypertension (55.4%), recent stroke (39.9%), and diabetes mellitus (36.3%). Nine patients had underlying solid organ cancer, but none had received chemotherapy or radiotherapy in the 3 months prior to admission.
Of 168 patients, 28 (16.7%) had tCDC, including 16 patients with fecal colonization at the time of admission and 12 who were colonized by toxigenic C. difficile during hospitalization (Figure 1). When the 16 patients with tCDC were compared with the 152 without tCDC at the time of admission, tCDC patients had a higher mean body weight (58.1 vs. 49.2 kg, respectively, P = 0.02) and were often associated with malignancy (18.8 vs. 3.9%, respectively, P = 0.04) (Table 1). However, there was no difference between the patients with and without malignancy in terms of prior therapy with cephalosporins (33.3 vs. 59.1%, respectively, P = 0.17), penicillins (33.3 vs. 17.6%, respectively, P = 0.37), carbapenems (44.4 vs. 30.8%, respectively, P = 0.47), or glycopeptides (22.2 vs. 17.6%, respectively, P = 0.66). Additionally, the groups did not statistically differ with respect to hospitalization within 3 months of admission, residence in a nursing home, nasogastric tube use or comorbid conditions. The results of the physical examinations and laboratory findings did not differ between patients with and without tCDC.
Of the 152 patients without tCDC at admission, 12 (7.9%) developed tCDC in an average of 38.5 (8–88) days after admission. There was no geographic clustering in the units where these 12 patients were located, and no contact with symptomatic patients with CDAD was identified. Nasogastric tube use and comorbid conditions were not associated with the development of tCDC during hospitalization (Table 2). Regarding recent medications, patients acquiring tCDC during follow up were more likely to have prior use of a glycopeptide (odds ratio [OR] 3.63, 95% confidence interval [CI] 1.06–12.45, P = 0.05). However, patients who had received more than one class of antibiotics (OR 6.67, 95% CI 1.41–31.56, P = 0.01), particularly a glycopeptide plus a cephalosporin (OR 4.50, 95% CI 1.20–16.87, P = 0.04) or a penicillin (OR 5.50, 95% CI 1.24–24.38, P = 0.04) or a cephalosporin plus a carbapenem (OR 3.63, 95% CI 1.06–12.45, P = 0.05), had a higher risk of tCDC. The use of other antibiotics or medications did not result in significantly different risks of tCDC (Table 2). The patients were categorized into four groups by prior exposure to a cephalosporin or penicillin, a glycopeptide, both, or none. tCDC developed in 21.7% of those ever receiving a cephalosporin or penicillin plus a glycopeptide, 6.3% of those with prior use of a cephalosporin or penicillin, and none of those with prior glycopeptide use or without antibiotic exposure (P = 0.05). Patients acquiring tCDC during hospitalization were more likely to have CDAD (25.0% vs. 1.4%, respectively, P = 0.003) and a longer hospitalization (35.0 vs. 20.1 days, respectively, P = 0.01) than those without tCDC.
Overall, 5 (17.9%) of 28 patients with tCDC developed CDAD compared to only 2 (1.4%) of 140 patients without tCDC (P = 0.002). Thus, during the 6-month study period, 7 (4.2%) of 168 patients experienced CDAD. The crude mortality rates of those with and without tCDC were similar (21.4%, 6/28 vs. 19.4%, 27/140, respectively, P = 0.79) (Figure 2).
The prevalence of tCDC, either at the time of admission or during hospitalization, among adults in the medical wards of a Tainan hospital was 16.7%. This is the first epidemiological study of fecal colonization by toxigenic C. difficile in Asia. In Hutin’s report in 1997, C. difficile colonization was found in 13.3% of patients admitted to infectious disease wards , similar to the 16.4% of those admitted to rehabilitation wards in Christina’s report . In Canada, 4.4% of hospitalized patients were found to have asymptomatic C. difficile colonization at the time of admission . In another study, 15% of patients without C. difficile colonization acquired C. difficile during follow up . The prevalence of C. difficile colonization may be as high as 20.4% in chronic care geriatric wards  and 51% among long-term care facility residents , . However, most of these studies were conducted in epidemic settings or high-risk populations. Outbreaks of CDI, particularly toxigenic strains such as ribotype NAP1/027, were reported in the Europe, United States and Canada. However, no recognized outbreak of CDI or the hypervirulent ribotype NAP1/027 strain was identified in Taiwan.
In this study, we found that patients with tCDC were more likely to develop CDAD in accordance with the finding of the study conducted by Lawrence et al. in which C. difficile colonization was an independent risk factor for C. difficile infection . However, the conclusion was contradictory in another investigation, which indicated that asymptomatic colonization with C. difficile was associated with a decreased risk of subsequent CDAD . The study was performed in 1998, and the rate of C. difficile colonization was evaluated using anaerobic cultures. Real-time PCR has been shown to have a high sensitivity for the detection of tcdB-carrying C. difficile isolates , . Fecal anaerobic cultures had a lower sensitivity for the detection of C. difficile, irrespective of toxigenic or nontoxigenic isolates than real-time PCR in our study, as indicated by the finding that 10 (3.9%) stool samples without C. difficile growth were positive for tcdB by real-time PCR. In contrast, no stool samples yielded toxigenic C. difficile and a negative real-time PCR result. Thus, it is generally believed that real-time PCR is an acceptable tool for studying fecal colonization with toxigenic C. difficile or CDAD.
The occurrence of CDAD has been associated with prolonged hospitalization , , . In chronic geriatric wards, the length of hospitalization was longer among patients with culture-confirmed fecal C. difficile colonization than that of non-colonized patients (21.6 vs. 11.7 days, respectively) . However, these C. difficile isolates were not evaluated for toxin production. Currently, little is known about the relative impact of the duration of hospitalization on the risk of subsequent toxigenic C. difficile colonization. In our study, the subjects colonized by toxigenic C. difficile during hospitalization had a longer hospital stay in the acute care wards. The increased mortality rate associated with CDAD is also of concern . However, our results were not in accordance with such a worrisome notion in western countries. It is likely that the absence of the hypervirulent C. difficile clone in Taiwan may have less of a health impact on infected patients.
The relationship between malignancy and CDAD was reported, particularly in patients with hematological malignancy ,  or who were receiving chemotherapy or radiotherapy ,  or a hematopoietic stem cell transplant , , and was attributed to the immunodeficiency observed in these patients , . However, there was no reported interaction between malignancy and tCDC, which was recognized by the univariate analysis in our study. Although prior antimicrobial therapy was not significantly different between individuals with or without malignancy, clinical studies including more cases may be warranted to define the independent clinical factors associated with tCDC.
Almost all antibiotics, including cephalosporins, penicillins, clindamycin, and quinolones, have been associated with CDAD , , , . However, the antibiotics associated with C. difficile colonization are unknown. Exposure to clindamycin , penicillins , or quinolones  before admission has been associated with C. difficile colonization. Nevertheless, we found that the use of glycopeptides or cephalosporins was associated with C. difficile colonization during follow up, although it was not statistically significant. Because prior cephalosporin therapy has been associated with CDAD , it is not surprising that we observed an association with C. difficile colonization. In contrast, prior glycopeptide treatment was not related to CDAD , , but in our study, there was a significant association between prior glycopeptide exposure and C. difficile colonization. However, the use of parenteral glycopeptide therapy in combination with other antibiotics, such as beta-lactam agents, may be the cause of the discrepancy. The association between C. difficile colonization and glycopeptide therapy may be related to glycopeptide-based combination therapy but not the glycopeptide itself. This was demonstrated in our study by categorizing the patients into four groups by prior exposure to β-lactams (cephalosporin or penicillin), glycopeptides, both, or neither; glycopeptide monotherapy was not associated with C. difficile colonization. Though the clinical use of more than one class of antibiotics has been associated with CDAD , , it is not clear which combination regimens are more likely to be associated with CDAD. However, we found that combinations of two classes of antibiotics, especially a β-lactam (either cephalosporin or penicillin) in combination and a glycopeptide, were more often related to C. difficile colonization than no antibiotic use.
There are several limitations inherent to our study. First, our case number was small, but this was a prospective cohort studied using a sensitive molecular method to detect toxigenic C. difficile colonization or infection. Second, the biological effect of fecal colonization with non-toxigenic C. difficile, which most likely will be different from that of fecal toxigenic C. difficile colonization, cannot be answered by the present study.
In conclusion, tCDC is a risk factor for developing CDAD, and the combination of glycopeptides and beta-lactam antibiotics was associated with C. difficile colonization. These findings may help us to create infection policies and define appropriate antibiotic use in patients with C. difficile colonization or CDI.
Conceived and designed the experiments: YPH WCK. Performed the experiments: KHH HCL CIL. Analyzed the data: HJL YHW. Contributed reagents/materials/analysis tools: PJT JJW WCK. Wrote the paper: YPH.
- 1. Kelly CP, LaMont JT (2008) Clostridium difficile–more difficult than ever. N Engl J Med 359: 1932–1940.
- 2. Chung CH, Wu CJ, Lee HC, Yan JJ, Chang CM, et al. (2010) Clostridium difficile infection at a medical center in southern Taiwan: incidence, clinical features and prognosis. J Microbiol Immunol Infect 43: 119–125.
- 3. Lin YC, Huang YT, Tsai PJ, Lee TF, Lee NY, et al. (2011) Antimicrobial Susceptibilities and Molecular Epidemiology of Clinical Isolates of Clostridium difficile in Taiwan. Antimicrob Agents Chemother.
- 4. McFarland LV, Mulligan ME, Kwok RY, Stamm WE (1989) Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 320: 204–210.
- 5. Clabots CR, Johnson S, Olson MM, Peterson LR, Gerding DN (1992) Acquisition of Clostridium difficile by hospitalized patients: evidence for colonized new admissions as a source of infection. J Infect Dis 166: 561–567.
- 6. Loo VG, Bourgault AM, Poirier L, Lamothe F, Michaud S, et al. (2011) Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med 365: 1693–1703.
- 7. Rudensky B, Rosner S, Sonnenblick M, van Dijk Y, Shapira E, et al. (1993) The prevalence and nosocomial acquisition of Clostridium difficile in elderly hospitalized patients. Postgrad Med J 69: 45–47.
- 8. Hutin Y, Casin I, Lesprit P, Welker Y, Decazes JM, et al. (1997) Prevalence of and risk factors for Clostridium difficile colonization at admission to an infectious diseases ward. Clin Infect Dis 24: 920–924.
- 9. Kyne L, Warny M, Qamar A, Kelly CP (2000) Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med. 342: 390–397.
- 10. Samore MH, DeGirolami PC, Tlucko A, Lichtenberg DA, Melvin ZA, et al. (1994) Clostridium difficile colonization and diarrhea at a tertiary care hospital. Clin Infect Dis 18: 181–187.
- 11. Walker KJ, Gilliland SS, Vance-Bryan K, Moody JA, Larsson AJ, et al. (1993) Clostridium difficile colonization in residents of long-term care facilities: prevalence and risk factors. J Am Geriatr Soc 41: 940–946.
- 12. McFarland LV, Surawicz CM, Stamm WE (1990) Risk factors for Clostridium difficile carriage and C. difficile-associated diarrhea in a cohort of hospitalized patients. J Infect Dis 162: 678–684.
- 13. Arvand M, Moser V, Schwehn C, Bettge-Weller G, Hensgens MP, et al. (2012) High prevalence of Clostridium difficile colonization among nursing home residents in Hesse, Germany. PLoS One 7: e30183.
- 14. Riggs MM, Sethi AK, Zabarsky TF, Eckstein EC, Jump RL, et al. (2007) Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 45: 992–998.
- 15. Lawrence SJ, Puzniak LA, Shadel BN, Gillespie KN, Kollef MH, et al. (2007) Clostridium difficile in the intensive care unit: epidemiology, costs, and colonization pressure. Infect Control Hosp Epidemiol 28: 123–130.
- 16. Shim JK, Johnson S, Samore MH, Bliss DZ, Gerding DN (1998) Primary symptomless colonisation by Clostridium difficile and decreased risk of subsequent diarrhoea. Lancet 351: 633–636.
- 17. Kvach EJ, Ferguson D, Riska PF, Landry ML (2010) Comparison of BD GeneOhm Cdiff real-time PCR assay with a two-step algorithm and a toxin A/B enzyme-linked immunosorbent assay for diagnosis of toxigenic Clostridium difficile infection. J Clin Microbiol 48: 109–114.
- 18. Knetsch CW, Bakker D, de Boer RF, Sanders I, Hofs S, et al. (2011) Comparison of real-time PCR techniques to cytotoxigenic culture methods for diagnosing Clostridium difficile infection. J Clin Microbiol 49: 227–231.
- 19. Persson S, Torpdahl M, Olsen KE (2008) New multiplex PCR method for the detection of Clostridium difficile toxin A (tcdA) and toxin B (tcdB) and the binary toxin (cdtA/cdtB) genes applied to a Danish strain collection. Clin Microbiol Infect 14: 1057–1064.
- 20. Bidet P, Lalande V, Salauze B, Burghoffer B, Avesani V, et al. (2000) Comparison of PCR-ribotyping, arbitrarily primed PCR, and pulsed-field gel electrophoresis for typing Clostridium difficile. J Clin Microbiol 38: 2484–2487.
- 21. Bidet P, Barbut F, Lalande V, Burghoffer B, Petit JC (1999) Development of a new PCR-ribotyping method for Clostridium difficile based on ribosomal RNA gene sequencing. FEMS Microbiol Lett 175: 261–266.
- 22. Marciniak C, Chen D, Stein AC, Semik PE (2006) Prevalence of Clostridium difficile colonization at admission to rehabilitation. Arch Phys Med Rehabil 87: 1086–1090.
- 23. Hornbuckle K, Chak A, Lazarus HM, Cooper GS, Kutteh LA, et al. (1998) Determination and validation of a predictive model for Clostridium difficile diarrhea in hospitalized oncology patients. Ann Oncol 9: 307–311.
- 24. Kent KC, Rubin MS, Wroblewski L, Hanff PA, Silen W (1998) The impact of Clostridium difficile on a surgical service: a prospective study of 374 patients. Ann Surg 227: 296–301.
- 25. McGowan AP, Lalayiannis LC, Sarma JB, Marshall B, Martin KE, et al. (2011) Thirty-day mortality of Clostridium difficile infection in a UK National Health Service Foundation Trust between 2002 and 2008. J Hosp Infect 77: 11–15.
- 26. Apostolopoulou E, Raftopoulos V, Terzis K, Elefsiniotis I (2011) Infection Probability Score: a predictor of Clostridium difficile-associated disease onset in patients with haematological malignancy. Eur J Oncol Nurs 15: 404–409.
- 27. Rampling A, Warren RE, Bevan PC, Hoggarth CE, Swirsky D, et al. (1985) Clostridium difficile in haematological malignancy. J Clin Pathol 38: 445–451.
- 28. Winkeljohn D (2011) Clostridium difficile infection in patients with cancer. Clin J Oncol Nurs 15: 215–217.
- 29. Sakai C, Kumagai K, Takagi T, Oguro M, Kimura H, et al. (1993) [An epidemic of Clostridium difficile colitis in patients with cancer: role of cancer chemotherapy and nosocomial infection in the pathogenesis]. Gan To Kagaku Ryoho 20: 2413–2416.
- 30. Chopra T, Alangaden GJ, Chandrasekar P (2010) Clostridium difficile infection in cancer patients and hematopoietic stem cell transplant recipients. Expert Rev Anti Infect Ther 8: 1113–1119.
- 31. Chopra T, Chandrasekar P, Salimnia H, Heilbrun LK, Smith D, et al. (2011) Recent epidemiology of Clostridium difficile infection during hematopoietic stem cell transplantation. Clin Transplant 25: E82–87.
- 32. Pant C, Sferra TJ, Ondrade C, Bass PF, Deshpande A, et al. (2011) Serum markers for severe Clostridium difficile infection in immunosuppressed hospitalized patients. J La State Med Soc 163: 91–94.
- 33. Schaier M, Wendt C, Zeier M, Ritz E (2004) Clostridium difficile diarrhoea in the immunosuppressed patient–update on prevention and management. Nephrol Dial Transplant 19: 2432–2436.
- 34. Spencer RC (1998) The role of antimicrobial agents in the aetiology of Clostridium difficile-associated disease. J Antimicrob Chemother 41 Suppl C21–27.
- 35. Pepin J, Saheb N, Coulombe MA, Alary ME, Corriveau MP, et al. (2005) Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 41: 1254–1260.
- 36. Bartlett JG (1992) Antibiotic-associated diarrhea. Clin Infect Dis 15: 573–581.
- 37. Thomas C, Stevenson M, Riley TV (2003) Antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea: a systematic review. J Antimicrob Chemother 51: 1339–1350.
- 38. Dial S, Alrasadi K, Manoukian C, Huang A, Menzies D (2004) Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. CMAJ 171: 33–38.
- 39. Chang VT, Nelson K (2000) The role of physical proximity in nosocomial diarrhea. Clin Infect Dis 31: 717–722.