¹Ex-Assistant Professor, ²Associate Professor, ³Professor & HOD, Department of Microbiology, Lokmanya Tilak Municipal Medical College & General Hospital, Sion Mumbai, INDIA.

Email: deshmrasika@gmail.com

Table 1: Age and Gender distribution of the study population

In present study, 11.66% of the cases were toxin positive; 5.83% males and 5.83% females and 22.5% of the cases were Culture positive; 14.16% males and 8.33% females;

Table 2: Toxin A/B and Culture results

Mean of length of hospital stay was 9.86 ± 2.96 in patients receiving mono- antibiotic therapy and 9.5 ± 1.79 in patients receiving poly-antibiotic therapy was seen. Length of hospital stay was more in patients receiving mono-antibiotic therapy No statistically significant difference between length of hospital stay and antibiotic therapy. (P=0.602)

Table 3: Antibiotic therapy and length of hospital stay (in days)

Mean of duration of first appearance of symptom was 6 ± 2.51 in cases receiving mono-antibiotic therapy and 5.86±1.61 incases receiving poly-antibiotic therapy was seen; Duration of first appearance of symptom was more cases receiving mono- antibiotic therapy. No statistically significant difference between duration of first appearance of symptom and cases receiving mono/poly antibiotic therapy. (P=0.813)

Table 4: Antibiotic therapy and duration of first appearance of symptom (in days)

In present study, 76.67 % cases had fever; 78.33 % cases developed diarrhea; 42.5 % cases complained of pain in abdomen.

Table 5: Symptoms

The risk of causing diarrhea is greatest with the Cephalosporins. Penicillin and Peptides have no significant role in increasing the risk of diarrhea

Table 6: Risk of Diarrhea according to the Class of Antibiotic

DISCUSSION

A major hindrance for the diagnosis of Clostridium difficile infection is demonstration of toxin production. The reason being slow turnaround time for isolation of the organism from stool specimen and also it is not a clinically useful diagnostic test and testing of stool specimen from asymptomatic patients will not yield any result. The Cell Culture Cytotoxicity assay (CCCA) has been replaced by more sensitive diagnostics. The most common testing method used today for C difficile toxins is the commercially available enzyme immunoassay (EIA), which detects toxins A and/ or B. Dependency on the culture may lead to false negative rate due to low sensitivity of this technique. Cell culture and ELISA’s are quite prolonged techniques, requiring well trained laboratory personnel and delay in diagnosis can cause more morbidity and mortality.¹⁰ Rapid diagnostic tests for detection of toxin A/B for Clostridium difficile are emerging extensively to provide rapid diagnosis of antibiotic associated diarrhea.¹¹ Our understanding of C. difficile epidemiology, pathogenesis, and diagnosis continues to evolve. The increase in CDI incidence and severity makes C. difficile one of the most important healthcare- associated pathogens. In addition, increase in the detection of CDI in previously low- risk populations pose new challenges which public health officials and healthcare providers will need to face. The use of such test to screen both GDH and toxin A/B will allow the laboratory to detect more samples without having to test these specimens to more expensive and time consuming test like cultures, EIA and PCR. In an Indian study done by Gogate A. et al.¹² in 250 children, maximum number of cases were seen in the age group of 5- 8 years. Similar findings were noted in present study. In a study done by Dutta P. et al.¹³ in 111 hospitalized pediatric patients, maximum number of cases were from 1- 2 years. As per study conducted by Brown KA. et al.¹⁴, there was increase in ward- level antibiotic exposure which was associated with increase in C difficile incidence as compared to Intensive care units. Similar findings were noted in present study. Overall 11.66% of the cases were toxin positive (5.83% males and 5.83% females). Also, when the patients were analyzed symptomatically, 14.89% of the patients who were having diarrhea were toxin positive (14/94). Sachu A. et al.¹⁵ noted male positivity rate for toxin as 65.6% and female toxin positivity was 34.4%. In the study by Dmitrieva N. et al.¹⁶ for the prevalence of Clostridium difficile- associated diarrhea in hospitalised patients, the overall toxin positivity rate was 21.7%. This was a bit higher than the present study. A study was conducted by Lashner B. et al.¹⁷ regarding the culture- positive but toxin- negative (CPTN) Clostridium difficile associated diarrhea. Amongst the isolates from CPTP patients, cytotoxin was produced by 97% as compared to 67% of isolates from CPTN patients which did not produce cytotoxin. The results suggest that C. difficile, in spite of absence of cytotoxin, may be an etiological factor in certain diarrheal syndromes. They recommended that until a randomized therapeutic trial for CPTN patients is conclusive, a positive culture should be considered as evidence for treatment of patients with persistent diarrhea. In a Chinese study by Ma H. et al.¹⁸ noted that incidence of AAD was significantly higher in the combined-use groups as compared to the monotherapy group, (44. 06% vs 17.16%, P<0.001). However, no statistically significant differences were found in the incidence of diarrhea between both the groups. In present study, incidence of AAD was significantly higher in the monotherapy groups as compared to the combined-use group,but there was no statistically significant differences found in the incidence of diarrhea between both the groups In the present study, exposure to the various classes of antibiotics cephalosporins (cefotaxime, cefoperazone and sulbactam, ceftriaxone), penicillin (amoxycillin and clavulanic acid, piperacillin and tazobactam), peptides (colistin, vancomycin), carbapenem (meropenem) and macrolide ( azithromycin) were evaluated, Since the majority of the cases were exposed to the first three class of antibiotics, so these class of antibiotics were analysed. The incidence of diarrhea was observed as: Cephalosporins: 87%, Penicillin: 67% and Peptides: 63%. Sachu A. et al.,¹⁵ noted that, the risk of causing diarrhea is greatest with the Cephalosporins. Penicillin and Peptides have no significant role in increasing the risk. Similar findings were noted in present study. In another meta-analysis by Deshpande A. et al.¹⁹ noted the association between the risk of CA-CDI and antibiotics, the risk was greatest with Clindamycin followed by Fluoroquinolones, Cephalosporins, Penicillin’s, Macrolides and Sulphonamides/ Trimethoprim. However, Tetracyclines were not associated with an increased CDI risk. Thus, Cephalosporins were associated with greater risk of diarrhea than Penicillin which goes in favour of the present study. A multi-centric retrospective cohort study was conducted by Watson T. et al.²⁰ to evaluate the risk factors for Hospital- Onset Clostridium difficile infections in a large healthcare system in the United States. They found that proton pump inhibitors increased the odds of a patient having hospital- onset Clostridium difficile infection as did third and fourth generation Cephalosporins, Carbapenems, and Piperacillin/ tazobactam. The risk with 1^st generation Cephalosporins, 3^rd generation Cephalosporins and 4^th generation Cephalosporins was more than Penicillin. The study findings go in concordance with the present study. Thus, the risk of causing antibiotic associated diarrhea or Clostridium difficile Infection is more with Cephalosporins as compared to Penicillin or Peptides. Clostridium difficile is proving itself to be genetically facile, which can increase its capability to adapt to new environmental circumstances and lead to the emergence of new epidemic and resistant strains. Finally, transition from EIA to PCR will probably improve our ability to detect and manage CDI but it is time consuming and expensive. Rapid test provide quick easy and cost effective means of accurately diagnosing CDI.

CONCLUSION

The risk of causing diarrhea is greatest with the Cephalosporins while penicillin and peptides have no significant role in increasing the risk of diarrhea. Use of rapid tests would save institutional costs, curtail unnecessary isolation days, reduce the nosocomial transmission of disease, and increase the quality of care for patients hereby decreasing the morbidity and mortality in hospitalized pediatric population.

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