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Increasing incidence and testing do not explain steep mortality rise associated to Clostridium difficile infection Brussels and Flanders, 1998-2007. Ignacio.

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Presentation on theme: "Increasing incidence and testing do not explain steep mortality rise associated to Clostridium difficile infection Brussels and Flanders, 1998-2007. Ignacio."— Presentation transcript:

1 Increasing incidence and testing do not explain steep mortality rise associated to Clostridium difficile infection Brussels and Flanders, Ignacio Gutiérrez, MD, MSc, Epiet Fellow A. Kongs, D. Mazina, N. Marin-Baldo Vink, M.L. Lambert

2 Background : Clostridium difficile Most frequent cause of nosocomial diarrhoea and involved in many outbreaks Spore forming and toxine producing Gram + anaerobe bacterium Found in the environment (soil, water, surfaces) Asymptomatic carriage in humans and animals Mild diarrhoea to life threatening pseudomembranous enterocolitis

3 Background: epidemiological notes Clostridium difficile infection (CDI) incidence and mortality increased in North America and Europe over the last decade Emerging hypervirulent fluoroquinolones-resistant strains (ribotype 027 and others) Changing environment due to antibiotics Outbreaks Belgium introduced moxifloxacine in 2002 and first ribotype 027 isolate dates from 2003

4 Objective To measure CDI-related mortality, incidence and number of tests performed for the period in Brussels and Flanders in order to provide evidence for public health action to reduce mortality

5 Methods: Data sources Mortality databases, Flanders and Brussels regions, ( ) >7 million residents Records with ICD-10 code for Clostridium difficile enterocolitis Hospital discharges database,( ), Belgium Records with ICD-9-CM code for intestinal CDI Social security (INAMI) database ( ), Belgium Number of CDI-diagnostic tests billed by year of performance Population data from the National Institute for Statistics

6 Methods: Data validation Mortality Comparison among ICD 10 codes: A04.7 (intestinal infection by Clostridium difficile) A00-A09( intestinal infections) K52.9 ("Noninfective gastroenteritis and colitis, unspecified") In order to detect possible code shifting

7 Methods: Statistical analysis Total and age- and sex-specific mortality rates for Hospital discharge rates for Direct standardization for mortality and hospital discharge rates by age, using Belgian 2000 midyear population Rate Ratios by year, using 2000 as a reference for Age-standardized mortality rates* Age-standardized hospital discharge rates* Rate* of diagnostic tests performed * Rates expressed in units per 100,000 general population

8 Clostridium difficile enterocolitis crude mortality rates in Brussels and Flanders,

9 Moxifloxacine Ribo 027

10 C.difficile enterocolitis as underlying cause of death, Brussels and Flanders Age- and sex-specific mortality rates

11 Clostridium difficile enterocolitis and other ICD-10 codes used for data validation, Brussels and Flanders

12 Clostridium difficile-associated disease hospital discharge rates in Belgian population,

13 Tests billed to diagnose C.difficile by the social security by setting and year of performance, Belgium,

14 YearN Test Rate Test RR N Disch Rate Disch RR N Mort Rate Mort RR ,760,92N.A. 100,150, ,250, ,100,93180,270, ,57Ref187618,30Ref240,35Ref ,781, ,100,99190,270, ,591, ,401,11530,722, ,631, ,101,481051,404, ,841, ,702,012323,018, ,821, ,802,172122,647, ,291, ,702,281622,005,71

15 YearN Test Rate Test RR N Disch Rate Disch RR N Mort Rate Mort RR ,760,92N.A. 100,150, ,250, ,100,93180,270, ,57Ref187618,30Ref240,35Ref ,781, ,100,99190,270, ,591, ,401,11530,722, ,631, ,101,481051,404, ,841, ,702,012323,018, ,821, ,802,172122,647, ,291, ,702,281622,005,71

16 YearN Test Rate Test RR N Disch Rate Disch RR N Mort Rate Mort RR ,760,92N.A. 100,150, ,250, ,100,93180,270, ,57Ref187618,30Ref240,35Ref ,781, ,100,99190,270, ,591, ,401,11530,722, ,631, ,101,481051,404, ,841, ,702,012323,018, ,821, ,802,172122,647, ,291, ,702,281622,005,71

17 YearN Test Rate Test RR N Disch Rate Disch RR N Mort Rate Mort RR ,760,92N.A. 100,150, ,250, ,100,93180,270, ,57Ref187618,30Ref240,35Ref ,781, ,100,99190,270, ,591, ,401,11530,722, ,631, ,101,481051,404, ,841, ,702,012323,018, ,821, ,802,172122,647, ,291, ,702,281622,005,71

18 YearN Test Rate Test RR N Disch Rate Disch RR N Mort Rate Mort RR ,760,92N.A. 100,150, ,250, ,100,93180,270, ,57Ref187618,30Ref240,35Ref ,781, ,100,99190,270, ,591, ,401,11530,722, ,631, ,101,481051,404, ,841, ,702,012323,018, ,821, ,802,172122,647, ,291, ,702,281622,005,71

19 YearN Test Rate Test RR N Disch Rate Disch RR N Mort Rate Mort RR ,760,92N.A. 100,150, ,250, ,100,93180,270, ,57Ref187618,30Ref240,35Ref ,781, ,100,99190,270, ,591, ,401,11530,722, ,631, ,101,481051,404, ,841, ,702,012323,018, ,821, ,802,172122,647, ,291, ,702,281622,005,71

20 YearN Test Rate Test RR N Disch Rate Disch RR N Mort Rate Mort RR ,760,92N.A. 100,150, ,250, ,100,93180,270, ,57Ref187618,30Ref240,35Ref ,781, ,100,99190,270, ,591, ,401,11530,722, ,631, ,101,481051,404, ,841, ,702,012323,018, ,821, ,802,172122,647, ,291, ,702,281622,005,71

21 Limitations Data: Mortality data- Brussels and Flanders Tests and hospital discharges- Belgium No complete data for Wallonia Validation only for mortality data ICD 10 code update in 2006

22 Conclusions Mortality due to Clostridium difficile enterocolitis increased in Brussels and Flanders during ,especially in the eldest So did Hospital discharge and the number of tests performed in Belgium Mortality increased faster in Brussels and Flanders than CDI-associated hospital discharges and number of tests in Belgium

23 Conclusions Mortality probably influenced by other changes in: virulence, specific treatment, exposure to ABs, OUTBREAKS... GOOD NEWS : DECREASING MORTALITY since 2004!!!

24 Recommendations A multidisciplinar aproach should lead to further research targeting hypervirulent strains and the role of antibiotic use in order to reduce C.diff. incidence and mortality It could be done from an international perspective if same trends are confirmed in other countries to optimize local resources by a coordinated aproach

25 Aknowledgements E.Kissling Epiconcept, Paris, France K. Bolaerts, S.Drieskens, E.Hendrickx, H.Van Oyen Scientific Institute of Public Health, Brussels, Belgium M. Dehnert RKI, Belin, Germany M.A.Luque PEAC, Madrid, Spain F.Luquero Epiet, Paris, France K.Alpers, A.Barrasa, M.A.Botrel, V.Bremer, B.Helynck, M.Muehlen, D.Radun Epiet coordination team Project review group

26 Trends for CDI-associated tests, discharge rates and mortality rates, Belgium

27 Belgium

28 Increase in C.diff.-related mortality rates, United States, Redelings MD, Sorvillo F, Mascola L. Increase in Clostridium difficile-related mortality rates, United States, Emerg.Infect.Dis. 2007;13(9):

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