Table 1.
Individual Studiesa
| Author | Study Period | Mid-Year | Continent | Study Design | N | N Diarrhea (%) | n (%) | n Diarrhea (%) | Method | Time | Definition | Age | ICU type (beds) Hospital |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Ang et al [13] | April 2004–April 2007 | 2005 | Europe | R Chart review | 1852 | NR | 62 (3.34%) | NR | Stool cytotoxin assay | >48 h | CDI: diarrhea and lab confirmation Diarrhea: ≥3 unformed stools/day for >2 d | >18 | General (8) Multiple injuries (8) |
| – | |||||||||||||
| Balassiano et al [14] | January 2006–July 2009 | 2007 | Europe | R Chart review | 458 | 218 | 43 (9.3%) | 43 (19.72%) | ELISA, culture, PCR targeting tpi gene and detecting cdtA cdtB cdtC | NR | Samples were tested at the discretion of the attending physician | NR | Medical/ Surgical (30) Tertiary |
| Buendgens et al [15] | February 1999–June 2010 | 2005 | Europe | R Chart review | 3286 | NR | 110 (3.35%) | NR | ELISA ± A/B DNA toxin detection through PCR | >48 h | CDI: a new onset diarrhea with typical endoscopy image ± microbiological confirmation | >14 | Medical (NR) University |
| Custovic et al [16] | January 2010–December 2010 | 2010 | Europe | P Cohort study | 834 | NR | 9 (1.1%) | NR | Reference to CDC | NR | Reference to CDC | NR | Surgical (NR) University |
| Dodek et al [17] | April 2006–December 2011 | 2008 | North America | R Chart review | 15 314 | NR | 236 (1.54%) | NR | EIA for toxins and common antigen, cytotoxin assay (tissue culture), or PCR | >24 h (after day 2) | CDI: ≥3 loose stools/day without other etiology and lab confirmation, typical pseudomembrane on endoscopy or toxic megacolon | >18 | Medical-Surgical University and community |
| Kelly et al [19] | March 1980–March 1981 | 1980 | Europe | P Cohort | 88 | 33 | 0 (0.00%) | 0 (0.00%) | Cytotoxin from fecal supernatants inoculated onto human embryonic lung fibroblast cells | >48 h | CDI: diarrhea and lab confirmation Diarrhea: >3 liquid stools a day as diarrhea | >9 | NR |
| Lawrence et al [20] | July 1997–December 1999 | 1998 | North America | R Cohort | 1872 | NR | 40 (2.14%) | NR | Cytotoxic assay | >24 h | CDI: positive for toxin A or B in an ordered specimen by the treating ICU physician | >16 | Medical (19) Tertiary Hospital |
| Lumpkins et al [21] | July 2004–October 2006 | 2005 | North America | P Cohort | 581 | NR | 19 (3.2%) | NR | Immunoassay for A and B toxins | NR | Samples were tested per signs and symptoms | NR | Trauma (NR) |
| Micek et al [22] | January 2009–December 2010 | 2009–2010 | North America | R Cohort | 5852 | NR | 267 (4.6%) | NR | Rapid membrane-filter immunoassay for both toxins A and B or real-time PCR to detect toxins or tcdC gene, Positive if toxin A, B, or both were detected. | >48 h | CDI: diarrhea or pseudomembranous colitis and lab confirmation | >18 | Medical and surgical (NR) University |
| Musa et al [23] | February 2003–January 2008 | 2005 | Europe | R Cohort | 5199 | NR | 27 (0.52%) | NR | EIA | >48 h | CDI: diarrhea officially defined and lab confirmation | >18 | Cardiothoracic – |
| Noto et al [24] | July 2012–July 2013 | 2013 | North America | R Cohort | 8068 | NR | 23 (0.29%) | NR | Reference to CDC | NR | Reference to CDC | >18 | Cardio (27), Medical (34), Neuro (34), Surgical (34) Tertiary |
| Rotimi et al [26] | July 1999–June 2000 | 2000 | Asia | P Cohort | 212 | 25 | 8 (3.77%) | 8 (32%) | ELISA | >96 h | CDI: diarrhea and lab confirmation ± endoscopic evidence and no other explanation for diarrhea Diarrhea: ≥6 loose stools/36 h |
>3 mo | General ICU (NR) Cancer ICU (NR) – |
| Salva et al [27] | January 2010–December 2011 | 2010 | Europe | R Chart review | 1936 | 177 | 7 (0.36%) | 7 (3.95%) | Immunochromatography or enzyme immunoassay | >48 h | CDI: diarrhea and lab confirmation Diarrhea: >3 watery stools/day or >200 g/day stool amount | >18 | Medical/Surgical (34) Tertiary |
| Shaughnessy et al [28] | January 2005–June 2006 | 2005 | North America | R Cohort | 1770 | NR | 87 (4.91%) | NR | ELISA for toxins A and B | >48 h | Sample was sent on the basis of physicians' clinical discretion | >15 | Medical (20) Tertiary |
| Silva et al [29] | June 2005–December 2009 | 2007 | Europe | R Cohort | 10 754 | 1080 | 15 (0.14%) | 15 (1.39%) | ELISA for either A and/or B toxin | >72 h | CDI: diarrhea or pseudomembranous colitis or toxic megacolon and lab confirmation | >18 | Open model (38) Tertiary |
| Thibault et al [30] | For 2 months | 2011b | Europe | P Cohort | 278 | 42 | 2 (0.78%) | 2 (4.76%) | NR | >24 h (up to 14 d) | CDI: diarrhea and lab confirmation Diarrhea: ≥3 liquid stools/day |
NR | Mixed medical/surgical (NR) Tertiary |
| Tripathy et al [32] | April 2008–August 2010 | 2009 | Europe | R Chart review | 2212 | NR | 9 (0.41%) | NR | EIA followed by GDH test and a positive toxin test | >48 h | CDI: diarrhea, toxic megacolon, or ileostomy with lab confirmation, pseudomembranous colitis (endoscopy or CT), positive biopsy result, positive fecal post-mortem sample with pseudomembranous colitis | NR | Neuro (14–20) Tertiary |
| Wang et al [33] | May 2012–January 2013 | 2012 | Asia | P cohort | 1277 | 124 | 31 (2.43%) | 31 (25%) | Stool DNA PCR kit for either toxin A or B detection. If positive followed by culture and toxinogenicity confirmation with multiplex PCR | >24 h | Sample collected if 3 or more loose stools/day | NR | Medical (50) University hospital |
| Zahar et al [34] | January 1999–January 2009 | 2004 | Europe | P Cohort | 5260 | 512 | 47 (0.9%) | 47 (9.18%) | EIA. Positive result if either toxin A or B is detected | ≥72 h | CDI: watery or unformed stools/day and lab confirmation of a stool sample positive | >18 | Medical-Surgical (NR) – |
| Hasham et al [18] | August 2009–October 2009 | 2009 | North America | P Chart review | 307 | 16 | 2 (0.65%) | 2 (12.5%) | NR | >72 h | CDI: diarrhea and lab confirmation Diarrhea: >3 episodes of loose stools/day | NR | NR |
| Pinto et al [25] | 2011 | 2011c | North America | R Chart Review | 2131 | 116 | 32 (1.5%) | 32 (27.59%) | PCR | NR | NR | 1 mo–21 y | Pediatric (NR) |
| Tirlapur et al [31] | January 2010– December 2010 | 2010 | Europe | R Cohort | 11 294 | 1278 | 119 (1%) | 119 (9.31%) | Antigen or toxin test | NR | CDI: diarrhea and lab confirmation | NR | NR (35) Tertiary |
Abbreviations: CDC, Centers for Disease Control and Prevention; CDI, Clostridium difficile infection; CT, computed tomography; EIA, enzyme immunoassay; ELISA, enzyme-linked immunosorbent assay; GDH, glutamate dehydrogenase; ICU, intensive care unit; lab, laboratory; NR, not reported; PCR, polymerase chain reaction.
a Characteristics of 22 studies: study period, mid-year, continent, number of patients evaluated and screened, number of patients with diarrhea, number of patients with CDI, method of C difficile detection, the age lower limit, information about the initial, time after ICU admission, definitions used per author, size and type of ICU and hospital.
b Two years before publication of the study.
c One year before the presentation/publication of the abstract.