# Incidence, Clinical Characteristics, and Outcomes of Clostridium difficile Infection in a Tertiary Care Center in Bahrain

## TL;DR

This study examines the incidence and risk factors of Clostridioides difficile infection in a Bahraini hospital, finding a low hospital-onset rate but rising community-onset cases.

## Contribution

The study provides new insights into CDI risk factors and outcomes in a Middle Eastern healthcare setting.

## Key findings

- HO-CDI incidence was 0.5 per 10,000 patient days with stable rates over time.
- CO-CDI cases increased, with most patients having recent antibiotic exposure.
- The ATLAS score reliably predicted mortality, with critical care admission and low albumin as key risk factors.

## Abstract

Background

Clostridioides difficile infection (CDI) represents a significant healthcare challenge associated with antibiotic use and healthcare settings. While healthcare facility-onset CDI (HO-CDI) rates have been extensively studied, the incidence and risk factors of CDI in various settings, including the community, require further investigation.

Aim

This study aims to examine the incidence rates of CDI in a major governmental hospital in Bahrain, identify risk factors for CDI, and assess the effectiveness of infection control measures.

Method

We conducted a retrospective study at the Salmaniya Medical Complex (SMC), analyzing all confirmed cases of CDI over a 30-month period from January 2021 to June 2023. CDI cases were screened using glutamine dehydrogenase antigen detection and confirmed using molecular assays like polymerase chain reaction and/or toxin assays for confirmation. The study categorized CDI cases based on their onset (hospital or community) and explored associated risk factors, including antibiotic use, proton pump inhibitor (PPI) therapy, and patient demographics. Infection control practices were also evaluated for their role in managing CDI.

Results

About 57 new CDI cases were identified during the study period, with a HO-CDI incidence rate of 0.5 per 10,000 patient days. While HO-CDI rates remained stable, community-onset (CO)-CDI cases increased. The median patient age was 61.8 years, without notable differences between genders. Key risk factors for CDI were antimicrobial therapy, use of acid-reducing agents, age, and underlying comorbidities. The mortality rate stood at 35.1%. The ATLAS score (i.e., age, treatment with antibiotics, leukocyte count, albumin level, and serum creatinine) was a reliable predictor of mortality. Critical care admission and low albumin levels emerged as significant independent risk factors for mortality.

Conclusions

The study demonstrates a low incidence rate of HO-CDI at SMC, attributed to effective infection control and antibiotic stewardship programs. The overall CDI rate increased during the study period, driven by a rise in CO cases; further investigating the risk factors among this category in our study revealed that most patients were exposed to antibiotic therapy within the past three months of their CDI diagnosis. The rise in CO-CDI cases underscores the need for broader community-based interventions and awareness regarding antibiotic and PPI use.