Clostridium difficile associated diarrhoea at Moi Teaching and Referral Hospital, Eldoret, Kenya

Abstract

Background: Clostridium difficile (C. difficile) is a spore-forming, toxin-producing, gram-positive anaerobic bacterium. It is the leading cause of nosocomial diarrhoea. C. difficile-associated diarrhoea (CDAD) is one of the most common healthcareassociated infections and a significant cause of morbidity and mortality among hospitalized patients. The prevalence rate of C. difficile infection/carriage in sub- Saharan Africa has been reported to range from 4.9 – 43%. Despite widespread access to over-the-counter antibiotics in Kenya coupled with high rates of nosocomial diarrhoea, patients are not tested for CDAD due to presumptions of low prevalence and technical inaccessibility. Objective: To determine the prevalence and describe the characteristics of patients with Clostridium difficile-associated diarrhoea (CDAD) at Moi Teaching and Referral hospital (MTRH), Eldoret, Kenya. Methods: In this cross-sectional study, 110 unformed stool samples were taken from the participants who were admitted and developed diarrhoea after 48 hours of antibiotic use or admitted with diarrhoea with a history of antibiotics use in the last 30 days. The samples were tested for C. difficile toxin B and the hypervirulent strain (027/NAP1/BI strain) by using the Cepheid GeneXpert® molecular method. Participants‟ age, sex and clinical characteristics were analysed using Chi-square test, Fisher‟s exact test and Wilcoxon rank sum test. A p value <0.05 was considered to be statistically significant. Results: One hundred and ten participants provided stool samples, of which 104 had valid PCR results. A majority (57.7%) of the participants were female with a median age of 39.5 years (IQR 25). CDAD was diagnosed in 23 (22.2% (95% CI 14.0- 30.2)) of the 104 participants whereas the hypervirulent strain was not detected in any of the samples. The median age of participants with CDAD was 42 years (IQR, 22) and 13 out of the 23 (56.5%) were female. There was a statistically significant association of CDAD with, prolong duration of hospitalization (p=0.02, Wilcoxon ranksum test); prolonged exposure to antibiotics ≥1 week (p=0.031, Fisher‟s exact test); exposure to >1 antibiotic (p=0.004, Fisher‟s exact test) and admission to surgical ward (p=0.01, Fisher‟s exact test). Both univariate and multivariate analysis showed that use of >1 antibiotic (OR, 3.3; 95% CI, 1.03-10.01; p= 0.04) was significantly associated with CDAD. Conclusion: CDAD is present in our setting, with a prevalence of 22.2%. CDAD is significantly associated with long duration of hospitalization, history of prolonged antibiotic exposure and use of multiple antibiotics. Recommendation: The diagnosis of C. difficile and testing for C. difficile toxins should be considered in persons who develop diarrhoea after history of antibiotic use.