Hindawi Publishing Corporation

Infectious Diseases in Obstetrics and Gynecology
Volume 2011, Article ID 267249, 8 pages
doi:10.1155/2011/267249

Research Article
The Emergence of Clostridium difficile Infection among
Peripartum Women: A Case-Control Study of a C. difficile
Outbreak on an Obstetrical Service

Jennifer A. Unger,1 Estella Whimbey,2 Michael G. Gravett,1 and David A. Eschenbach1
1 Department of Obstetrics and Gynecology, University of Washington, Seattle, P.O. Box 356460, WA 98195-6460, USA
2 Department of Medicine, University of Washington Medical Center, Seattle, WA 98195-0001, USA

Correspondence should be addressed to Jennifer A. Unger, junger@u.washington.edu

Received 1 November 2010; Revised 12 April 2011; Accepted 25 May 2011

Academic Editor: Patrick Ramsey

Copyright © 2011 Jennifer A. Unger et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Objective. An outbreak of 20 peripartum Clostridium difficile infections (CDI) occurred on the obstetrical service at the University
of Washington Medical Center (UWMC) between April 2006 and June 2007. In this report, we characterize the clinical
manifestations, describe interventions that appeared to reduce CDI, and determine potential risk factors for peripartum CDI.
Methods. An investigation was initiated after the first three peripartum CDI cases. Based on the findings, enhanced infection control
measures and a modified antibiotic regimen were implemented. We conducted a case-control study of peripartum cases and
unmatched controls. Results. During the outbreak, there was an overall incidence of 7.5 CDI cases per 1000 deliveries. Peripartum
CDI infection compared to controls was significantly associated with cesarean delivery (70% versus 34%; P = 0.03 ), antibiotic
use (95% versus 56%; P = 0.001), chorioamnionitis (35% versus 5%; P = 0.001), and the use of the combination of ampicillin,
gentamicin, and clindamycin (50% versus 3%; P < 0.001 ). Use of combination antibiotics remained a significant independent risk
factor for CDI in the multivariate analysis. Conclusions. The outbreak was reduced after the implementation of multiple infection
control measures and modification of antibiotic use. However, sporadic CDI continued for 8 months after these measures slowed
the outbreak. Peripartum women appear to be another population susceptible to CDI.

1. Introduction in 2006; the estimated CDI incidence among peripartum
women increased significantly from about 0.4 to 0.7 per
The patient populations susceptible to Clostridium difficile 100,000 deliveries over this period [6]. While the apparent
infection (CDI) have now broadened to include pregnant lower rate of CDI in peripartum than nonpregnant patients
women. In nonpregnant populations, both the incidence and explains the sporadic reporting of peripartum CDI [7–10],
severity of CDI have increased over the past decade. Recent severe manifestations including septic shock, toxic mega
large CDI outbreaks in Canada and U.S.A. demonstrated an colon, and even death occur in the peripartum population
increase CDI infection rate from a baseline of 2–6 infections [8–10].
per 1,000 hospitalized discharges (HD) in the 1990’s [1–3] Antibiotics significantly decrease both maternal and
to 10–20 infections per 1,000 HD during recent outbreaks neonatal infections, but they also are the primary risk factor
[4, 5]. As with nonpregnant patients, the incidence of CDI for CDI, the leading cause of nosocomial infectious diarrhea
also has increased significantly in peripartum women. Using [11]. Antibiotics disrupt normal bowel flora and promote
the Nationwide Inpatient Sample of all payer U.S. hospital colonic C. difficile overgrowth and subsequent exotoxin
discharges, the number of nationally reported peripartum production. Prolonged antibiotic and multiple antibiotic
CDI cases doubled from 129 cases in 1998 to 294 cases uses are particularly associated with CDI [12]. Exposure to

Only two diarrhea were placed on contact precautions until a negative peripartum CDI cases were identified at UWMC in the prior toxin result was available. In with hard wood laminated floors. difficile antitoxin (an internally validated ganisms causing peripartum infection [20] and institutional UW assay) [19]. A thorough cleaning by diarrhea and evidence of CDI documented by either a of the antepartum. step-wise comprehensive infection control The University of Washington Medical Center (UWMC) measures similar to the previously described “bundle” is a 450 bed tertiary care teaching hospital with a high. gentamicin and clindamycin with or without the addition of ampicillin continue to be a popular regimen to treat peripartum infection [18]. difficile a chlorine-based product (Bru-Clean TbC) rather than the was identified in fecal specimens assayed simultaneously routine hospital quaternary ammonium disinfectants as for C. a multidisciplinary team of providers and infec- cytotoxic effects on human diploid fibroblast cells that were tion control specialists reviewed the most common microor- neutralized by C. specimens were assayed for cytotoxin B demonstrated by Finally. about 10% of women develop chorioamnionitis or postpartum endometritis infection requiring antibiotics Figure 1: Clostridium difficile infection outbreak timeline and [16]. After the first three cases of CDI. premature rupture of membranes (PPROMs).S [14] and for the 15–20% of women with vaginal Group B strepto. Addi- tionally.2 Infectious Diseases in Obstetrics and Gynecology C. postpartum and positive assay for C. Several cases had more than one stool susceptibility data to commonly used antibiotics. A case of peripartum CDI was defined previously used alcohol-based scrub. 13]. By August 2006. and results were consolidated in the antibiotics with a reported high resistance to C. Further. (2) outline specific staff underwent intensive formal education and training on infection control measures and antibiotic modifications that CDI prevention strategies (Table 3). difficile positive patients. difficile. “Bundle” Interventions. Materials and Methods use of gowns and gloves with any contact with a presumed or confirmed CDI case. Carpet in the provider workrooms was replaced gene and toxin B gene (an internally validated UW assay). result. Patients with confirmed CDI were five years. the first case of peripartum CDI in two years isolation that consisted of single room occupancy and gown was identified.Up to 50% 3 of pregnant women now are exposed to antibiotics during 2 a hospital delivery. prophylactic antibiotics are used for the 1 30% of women undergoing cesarean section in the U. All health care providers may have limited the outbreak. ticarcillin/clavulanate (Timentin) was routinely used to treat chorioamnionitis and postpartum endometritis. we sought to (1) characterize the initially treated with a ten-day course of oral metronidazole. over the following fifteen months. Clindamycin was restricted to severe or unusual infection. the treatment was standardized for chorioamnionitis and post- data was verified to represent the test date that corresponded partum endometritis to reduce the utilization of multiple to the diagnosis of CDI. difficile common antigen and toxin A by enzyme currently recommended [12]. 5 investigation changes Initiation of hcare workers [1. Specimens that were installed by the operating room on labor and delivery to antigen positive. at the discretion of the primary care provider. Steps were made for the addition. difficile infection patient environment and equipment was disinfected using in a peripartum female. risk referral obstetrical service and 2200 annual deliveries. difficile spores occurs from direct transmission among 6 Infection Environmental Initiation of control cleaning antibiotic hospitalized patients or indirectly through fomites and healt. difficile A or B toxin in the stool or outpatient clinic areas took place in September 2006. The presence of toxigenic C. In such cases. Contact precautions included the 2.1. Ampicillin and erythromycin use was continued for preterm tigation and infection control audit July 2006 (Figure 1). ICU care and elderly age [2]. CDI risk factors in nonpregnant staff training 4 CDI cases populations also include prolonged hospitalization as well as underlying disease. All patients with twenty peripartum CDI cases were documented. water hand washing before and after any contact with C. . All colonic histopathology characteristic of C. difficile 16 S deliveries. and (3) determine potential were required to use contact precautions and soap and risk factors of peripartum CDI through a case-control study. but toxin A negative were cultured for C. Patients with confirmed CDI were placed in strict contact In April 2006. the UWMC Infection Control Department started an inves. make clean scrubs readily accessible to providers after all difficile. all providers and sustained peripartum CDI outbreak. Thus. Antibiotic sample submitted for diagnostic testing. a water-based scrub was Peripartum was defined as four weeks before and four required for the first surgical case of the day instead of the weeks after delivery. difficile Panel). approach [5] were initiated on the obstetrical unit (Table 3). As a result section and in Table 1. fecal immediate diagnoses of CDI among patients with diarrhea. Although single extended spectrum antibiotics pro- interventions. a total of and glove used by all visitors and personnel. vide comparable infection cure rates to multiple antibiotic regimens for postpartum endometritis [17]. clinical manifestations and outcomes of the first reported Immediately following the first cases. A provider change room was immunoassay (Triage C. followed by PCR molecular testing for C. In this report. 0 “2005” “2008” Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 coccus colonization to prevent neonatal infection [15]. 2. labor and delivery.

Ceph. D 2 (Re-ad) Placenta previa. mode of delivery: VD: vaginal delivery. POS ND ND F. Pulm. gentamicin. . 3 Amp/Gent/Clinda: ampicillin. D 3 (Re-ad) hysterectomy Ceph 23 1 PP Chorio 39 CS Amp/Gent/Clinda NEG POS ND F. and clindamycin. 41 3 pp 37 CS Aug/Azy/Ery. 21 1 26 PPROM. PPROM: preterm. hospital days: LOS: length of stay. D 1 (Re-ad) Neck venous 24 1 pp 37 CS Ceph NEG POS ND D 0 (OP) malformation Class RF DM. antibiotic type: clinda: clindamycin. or erythromycin. PPROM. POS ND ND F. F. Re-ad: patient readmitted. PTL. PP Amp/Gent/Clinda. D 5 (Re-ad) Aug/Azy/Ery. D 0 (Ante) Ceph. POS POS POS F. D 0 (OP) Aug/Azy/Ery. Aug/Azy/Ery: augmentin. 25 3 PP 37 VD POS ND POS F. GHTN: gestational hypertension. Table 1: Clinical characteristics and diagnostics of peripartum CDI cases. pyelo: pyelonephritis. D. chorio 27 CS Aug/Azy/Ery. D Long LOS Other 22 1 pp PPEM 41 CS Ceph. OP: outpatient therapy). premature rupture of membranes. test results: ND: not done. CS: cesarean section. 26 1 22 Fetal anomalies 23 VD None NEG POS ND D 5 CHTN Amp/Gent/Clinda. 39 1 27 29 VD POS ND ND F. Ceph: cephalosporin. D 1 (Re-ad) Amp/Gent/ 31 1 pp PPEM 39 CS Clinda. Amp/Amox. D Long LOS Twins. POS ND POS 8 Colectomy Ceph 19 1 pp Chorio 41 CS Amp/Gent/Clinda POS ND POS F. 49 1 pp Mastitis 42 CS Aug/Azy/Ery. D 3 (Re-ad) Amp/Amox Chorio. PPEM: postpartum endometritis. PPEM 34 VD Aug/Azy/Ery. D 4 (Re-ad) Ceph 20 1 pp Osteosarcoma Pyelo. D Long LOS chorio Aug/Azy/Ery Clinda. Ceph Clinda. D Long LOS Embolus. 26 6 pp PPROM. Total 52 5 pp Twins. POS ND ND F. days due to CDI onset (wks) complications delivery (EIA) (cytotoxin) illness (wks) (PCR) diarrhea) CDI 31 0 31 Marfan’s Synd. PPEM 36 CS Amp/Gent/Clinda. chorio: chorioamnionitis. Pneumonia 36 CS NEG POS ND F. Other Amp/Gent/Clinda. Other 25 1 pp Chorio 41 CS Amp/Gent/Clinda POS ND POS F. POS ND ND F. azythromycin. other POS ND ND F. 38 4 pp Chorio 38 CS POS POS NEG F. D 3 (Re-ad) Other Infectious Diseases in Obstetrics and Gynecology Amp/Gent/Clinda. pyelo (Obstetric complications: PTL: preterm labor. PTL 36 VD Clinda NEG ND POS F. Amp/Amox: ampicillin or amoxicillin. Twins. severe GHTN 28 VD Other NEG POS ND F. D 0 (OP) 29 3 pp 38 CS Ceph POS ND ND D 0 (OP) Amp/Gent/Clinda. 38 7 pp 30 CS Other POS ND ND D 0 (OP) abruption. PPEM Ceph. Significant Gestational age Toxin B Outcome Hospital Gestational age at Obstetric Mode of Toxin A Toxin B Age Parity underlying at delivery Antibiotic type gene (fever. 32 3 26 Sickle Cell Dis.

Infection control remains ampicillin. 38. and use of the antibiotic combination of clindamycin. She remained hospitalized and delivered at 29 weeks 2. All 20 fifteen-month outbreak. difficile EIA assay for Toxin A alone in eight patients. Two additional cases received clindamycin: one alone for database of deliveries during the study period. The next morning.9◦ temperature and received ampicillin. use. postpartum unit could have contributed to the outbreak version 12. Antibiotics were occurred on the obstetrical ward prior to the outbreak. Patients received antibiotics for both prophylaxis and to Thus. and sickle cell anemia with crisis. Two Human Subjects Committee no. seven cases were diagnosed during their delivery oral and rectal vancomycin. laboratory and outcome data were abstracted from for mastitis. antibiotics (Table 1) for one week. but no the presence of a positive C. The study was approved by the UWMC from C. One C. Ten of the 20 who delivered during the outbreak period of April 2006 cases received a combination of ampicillin. GBS prophylaxis and one together with other antimicrobials clinical. hospitalization. The first patient received clindamycin Toxin A and a positive cytotoxin assay for Toxin B were alone for preterm labor GBS prophylaxis at 32 weeks identified in her stool on postoperative day 5. The antibiotic transition strategies were gradually phased in and second case presented with PPROM at 27 weeks and received became routine by early 2007. A total of 8 patients required hospital readmission after gentamicin.000 deliveries. Statistical Methods. delivery for diarrhea and fever. she cytotoxin assay for C. Demographic. All tests were 2 tailed. difficile PCR and/or cytotoxin deaths occurred in this series. The second hospitalization at 36 weeks gestation (Table 1).0 (SPSS). difficile Toxin B was identified in developed septic shock: oliguria. The patient had a twin gestation. and ampicillin were included in the model. then amoxicillin. and mode of delivery. The patient delivered during a sively implemented until after the outbreak peaked. The discontinued on the 4th postoperative day. treat infections. CDI was diagnosed by the presence of a positive in 9 cases and a creatinine of greater than 1. 36114 under minimal risk discharged postpartum patients were treated with outpatient criteria. and by the presence of A 52-year-old postpartum case suffered a toxic mega- positive assays for both Toxin A and B in six cases (Table 1). Results eight patients readmitted for CDI required a total of 22 extra inpatient days or an average of almost 3 extra days per case. We performed chi-square (χ 2 ) and they were among the 5 patients with long-term antepartum Fischer’s exact tests for univariate analysis of categorical hospitalizations for significant chronic illnesses including variables and Mann-Whitney U tests for continuous vari. difficile contamination of this hospital area. All of these statistically significant.5 CDI cases per 1.2. Using a random number table. A positive EIA assay for C. Data abstracted included clindamycin. 2. A total of 2671 deliveries occurred patients presented with diarrhea. We performed a logistic regression 5 also had significant obstetrical complications. CDI symptoms developed frequent changing of scrubs.3.05 was considered osteosarcoma. class RF diabetes. a . she developed a ward. strict contact precautions. tachycardia. A positive promptly placed on metronidazole. The indication for antibiotic use and actual partum CDI cases to randomly chosen unmatched controls antibiotic exposures are presented in Table 1. Extra days of hospitalization for those inpatients diagnosed with CDI cannot be precisely calculated. Three cases received antibiotics for infections unrelated to pregnancy. of hospitalization. hypotension. for C. colon and required an emergent colectomy despite prompt Three cases developed CDI during a separate antepartum oral metronidazole treatment for one day and subsequent admission. A positive EIA assay a narrow spectrum of antibiotic choices. Two cases received a cephalosporin included CDI risk factors such as age. and erythromycin and other heightened on the unit including soap and water washing. including using CDI as the outcome. Fever during CDI was over this time for an incidence of 7. length CDI in September received no antibiotics.000 documented in 16 cases. alone for Cesarean prophylaxis. chronic hypertension. a leukocytosis of greater than 15. gentamicin. postpartum endometritis in 12 of the 20 patients. One patient diagnosed with specific peripartum antimicrobial indication and use. eight of whom required readmission. Twenty peripartum CDI cases were identified during the The morbidity among the cases was significant. but she developed first two cases of the outbreak were diagnosed during the diarrhea later that day. gentamicin. gent cesarean section. ables. and to June 2007. On postoperative day 2. we performed a case-control study comparing peri. She received cefazolin prophylaxis Hospital readmission occurred back into the postpartum with surgery. Thus. assay for Toxin B alone in six patients.4 Infectious Diseases in Obstetrics and Gynecology The infection control “bundle” strategies were progres. antibiotic premature delivery. and she was gestation and developed diarrhea 7 days later. by patient developed septic shock and toxic mega colon. No patient was Antibiotics were used to treat chorioamnionitis and/or excluded. and a P < . and six days after discontinuing antibiotics. difficile antepartum period. and ten postpartum cases were diagnosed one twin delivered vaginally and the second twin by emer- after hospital discharge. The mode of delivery. 12 of the 20 cases received a regimen that medical records of both cases and controls. her stool on hospital day 8. and No significant clinical or antibiotic management change clindamycin for postpartum endometritis.0 in 4 cases. Case-Control Study. therapy. Peripartum CDI risk factors may gestation. Marfan’s syndrome. four controls clindamycin for chorioamnionitis or postpartum endometri- (n = 80) per case were selected from a hospital perinatal tis. but the 3. difficile Toxin A was detected in her stool the next day. The readmission to the Statistical analyses were performed with SPSS for Windows. underlying disease. differ from those reported in CDI of nonpregnant adults.

significant underlying illness (25% versus 7.7 (3.001).001).3) .4 mg/dL.2 0. any antibiotic use.3–73.7 (9.4).04 Prior antepartum 11 (55%) 2 (3%) 47.0).3) 0. been previously hospitalized during Vancomycin was begun both by a nasogastric tube and the pregnancy (55% versus 2.4 (.001 hospitalizations Complications Preterm labor 2 (10%) 8 (10%) 1. and a significant of toxin megacolon and pseudomembranous colitis. 95% 36 months since outbreak ended June 2007.0.D.1–91. and a creatinine of 2. chronic hypertension.8) 0. labor and a diagnosis of chorioamnionitis or postpartum All infection control measures were implemented by endometritis.9–6.8 (1.6 (1.2 Ethnicity Caucasian 12 (60%) 41 (51%) African American 3 (15%) 8 (10%) Hispanic 3 (15%) 14 (18%) 0. She presented with sepsis. Histopathologic syndrome.3 (0. ing the 20 CDI cases with 80 randomly chosen unmatched Three risk factors in the univariate analyses were controls are presented in Table 2. This patient CI 1.0) <.2 Cefazolin/Keflex 10 (50%) 24 (30%) 2.001 Clindamycin alone 2 (10%) 2 (3%) 4.9–39.20–5.9) and postpartum prescribing protocols were in place by spring of 2007.4) .0 (7.5) 0.2–15.9) .06–1.9–115.9 THOU/μL). leucocytosis (12.0 (2.0) 0. Thus. Case-Control Study. P = 0. CDI was associated with both chorioam- the end of January 2007 (Figure 1).6 ± 9. The patient’s clinical condition worsened on postoperative Underlying illness in the case group included Marfan’s day 7.9–115.4 (8.001 Postpartum endometritis 5 (25%) 2 (3%) 13. osteosarcoma.1. versus 34%. This neck venous malformation.001 ∗ Categorical variables testing using chi-square or Fischer’s exact test. One endometritis (OR 13. Cases (N = 20) Controls (N = 80) OR (95% CI) P-value Mean age ± S. used for 10 cases and only 1 control (P < . continuous variables tested using the Mann Whitney U test.0 ± 7.001). The two groups did not both strongly associated with CDI and with each other: differ in age or ethnicity. CDI from an outside hospital.0) <.5%.57–32. P = 0.2 (2.001 Antibiotic combinations Amp/Gent/Clinda 10 (50%) 2 (3%) 39.001 >3 doses of IV antibiotics 18 (90%) 14 (18%) 42.0 PPROM 3 (15%) 4 (5%) 3.03 Cesarean section Significant underlying illness 5 (25%) 6 (8%) 4. and have rectally. and a positive Toxin B assay.0 (.03).9 Asian/Pacific Islander 1 (5%) 8 (10%) Other/unknown 1 (5%) 8 (10%) Mode of delivery 14 (70%) 27 (34%) 4. 30.9–39. The combination of ampicillin/gentamicin/clindamycin was pseudomembranous colitis.8–204.6–13. 95% CI 7.5–204.1 (1.1) 1. 95% CI 2.0. Univariate analyses results compar.1–250.3–73. Three or more intravenous antibiotic doses (range 3 to 40 doses) were 3.2) 0. class RF diabetes. sickle cell examination of the resected colon confirmed the diagnosis anemia with sickle crisis.5–204.003 Any antibiotic use 19 (95%) 45 (56%) 14.3 29.1 Chorioamnionitis 7 (35%) 4 (5%) 10.04). and she was transferred to the intensive care unit. received by 18 cases and only 14 controls (P < . and a total colectomy was performed.3) 0.8) as was the use of the combination ampi- was not included in the report because she transferred with cillin/gentamicin/clindamycin (OR 39.5%. Women with CDI were more likely cesarean section delivery.3 (. Changes to antibiotic nionitis (OR 10.8. 95% CI 2.Infectious Diseases in Obstetrics and Gynecology 5 Table 2: Selected characteristics of CDI cases and of randomly selected controls. P = 0. and use of than controls to have undergone a cesarean section (70% ampicillin/gentamicin/clindamycin. these three risk .9 Other 6 (30%) 2 (3%) 16. patient had no significant baseline risk factors for CDI except CDI cases undergoing cesarean section often had a long for her age. The use of any additional cases of peripartum CDI was diagnosed in the antibiotic was strongly associated with CDI (OR 14.9) 0.2.

given to 90% of cases. 18]. aminoglycosides. 21]. However. for many. is popular in labor and delivery units because of its wide (3) Positive protective equipment (PPE) for potential exposure microbial coverage [17. The NAP1 C. This potent combination of antimicrobials when hands are visibly soiled. antipseudomonal penicillins. Antibiotic use is particularly high in modern outbreak of Clostridium difficile Infection (CDI).001). The case rate of 7. nonpregnant adults [4. and it was used at UWMC for (a) Gowns and gloves for contact with any suspected and both chorioamnionitis and postpartum endometritis for the documented CDI cases. difficile. independent of the mode of delivery and any (b) Water-based surgical scrub for the first case of the day. damycin resistance in our report. of CDI suggests that the regimen of ampicillin. despite a marked reduction in CDI after . its long time of use at UWMC may have acted synergistically (4) Environmental and equipment cleaning to contribute to the outbreak. have been implicated in CDI. TimentinR multiple antibiotic regimen use. Obstetrical units should pay per 1000 admissions where the diagnosis was extracted from close attention to antibiotic use and be prepared to institute microbiology laboratory log data [21]. gentamicin. variate analyses. factors were examined in a logistic regression. Since the outbreak. 5]. or. in order of higher to a lower magnitude includes: cillin/gentamicin/clindamycin persisted as an independent second and third generation cephalosporins. ampicillin. A PubMed search of English citations from from its ability to produce 16 to 23 times more toxin A and B 1966 to April 2011 confirms previous reports of only up in vitro than toxin type O strains [26. and 3 or more antibiotic doses were infection control. quinolones. amoxicillin or risk factor for CDI (P < 0. difficile at UWMC and an expected comparable infection (c) Good antibiotic stewardship with minimal clindamycin and treatment result [17] made the switch logical. past 20 years. In contrast to these outbreaks. [23] and 60% of our (5) Diagnosis and treatment cases received clindamycin. (a) Extensive environmental cleaning and disinfection of the entire C difficile recovered from cases was not tested for clin- unit and outpatient clinic with a hypochlorite-based disinfectant. (b) Contact precautions for all suspected and documented CDI Examination of antibiotics used prior to the development cases. Both the multiple antibiotic combinations and (b) Frequent change of scrubs and protective garments. This confirmed the strong ampicillin with clavulanic acid. although extended penicillins. CDI infections per 1000 deliveries over the 15 months of this Strong environmental control measures and an infection outbreak was comparable to the rate of 10–20 CDI infections control “bundle” together with antimicrobial stewardship per 1000 hospital discharges during recent CDI outbreaks in are recommended to control a CDI outbreak [5. quinolones were partic- ularly singled out with a population attributable fraction This peripartum CDI outbreak is the largest sustained of 36% [25]. 21. and penicillin [24]. In a binary A meta-analysis on the CDI risk from various antimicro- logistic regression model. (a) Thorough hand hygiene with soap and water rather than an Repeated doses of this antibiotic regimen were strongly alcohol-based hand gel when caring for patients with suspected or associated to CDI in both the univariate and in the multi- documented CDI. in the cessation of this outbreak. Multiple (1) Contact precautions antibiotics were used simultaneously and/or sequentially in (a) Intensive education and training in the fundamentals of 85% of the CDI cases. The 56% widely from 0.6 Infectious Diseases in Obstetrics and Gynecology Table 3: Infection control measures used for an obstetrical service exposure. Fluoroquinolones to 4 peripartum CDI cases in one institution [9]. the use of the combination ampi. 56% of the UWMC control patients in this study received at least one antibiotic dose. like all antibiotics. and antibiotic use.5 antibiotic rotation. 27]. However. prior ICU stay. such as occurred here. 28. Prior are relatively contraindicated in pregnancy. Previous reports found that up to 80% of C. caries a <1% resistance to C. our 29]. and behavioral infection control measures and antibiotic Two well-recognized CDI risk factors were present in changes were put in place simultaneously until the outbreak almost all but one case: prior antimicrobial use and hospital ended. so they were reports estimated the rates of peripartum CDI to range not a factor in this peripartum CDI outbreak. difficile strain is not only outbreak reported to date on a labor and delivery unit fluoroquinolone resistant. has been used to treat chorioamnionitis and endometritis. delivery services. It is impossible to assess the relative impact of the patients were young women without typical risk factors such environmental interventions compared to antibiotic change as prolonged hospitalization. 8–10. C. association present in the univariate analysis. but antibiotic resistance (b) Replace carpet in provider work rooms with laminated hard contributed to hypervirulent CDI strains in other outbreaks wood floors [22]. difficile isolates were resistant to clindamycin. Discussion NAP1/027 CDI Quebec outbreak. (b) Prompt treatment of documented CDI or suspected CDI in The lack of TimentinR (ticarcillin/clavulanate) resistance to seriously ill patients.7 per 100. bials listed.4 to 0. (2) Hygiene and clindamycin was a major factor in the outbreak. but the hypervirulence is derived [6. clindamycin. Stepwise environmental significant underlying illness.7 both astounding and common. TimentinR (a) Prompt diagnosis of patients with diarrhea. in the recent serious hypervirulent 4.000 deliveries where the antibiotic use rate in a delivery unit such as at UWMC is diagnosis was made from national coding data [6] to 0.

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