To the Editor: Clostridium difficile NAP/BI/027 is a hypervirulent form of the bacterium C difficile. NAP/BI/027 is a highly resistant strain, and infection with C difficile is associated with high morbidity and potential mortality. There has not been any reports of this strain in Saudi Arabia. However, its detection requires PCR techniques that are not widely available. We describe four cases of C difficile NAP/BI/027 infection observed in our institution over a one-year period, no relatedness found between any of the cases. All patients were >60 years of age and had a number of premorbid conditions. They received long courses of antibiotics before they developed diarrhea and tested positive for C difficile NAP/ BI/027. All were treated with metronidazole and/or oral vancomycin. One patient developed toxic megacolon and expired, whereas the other three patients made a gradual recovery and were discharged. This report confirms that C difficile NAP/BI/027 exists in this region of the world and is likely underdiagnosed due to the need for specific PCR-based testing that is not widely available. This strain is highly resistant to fluoroquinolones and is associated with severe disease and high mortality rates.1 The epidemiology of this organism has changed drastically in recent years. The incidence and severity of C difficile infection have increased considerably in the USA, Canada, and Europe. Several outbreaks in these countries have occurred, caused mainly by ribotype 027.2,3 Three cases of NAP/BI/027 C difficile infection were reported in Asia but this strain has never been reported in Saudi Arabia.4–6 We describe the first four unrelated cases of C difficile NAP/ BI/027 diagnosed at our hospital.
CASE 1
A 66-year-old male diabetic and hypertensive patient was admitted to the hospital on June 14th 2011 with sternal wound infection post-coronary artery bypass graft. He was started on imipenem on June 20th for 5 weeks. Then ciprofloxacin and vancomycin were added and continued for 4 weeks. On July 29th, the patient began to have diarrhea. A stool sample tested positive for C difficile NAP/BI/027 via PCR. The patient was treated with metronidazole. The diarrhea stopped, and he continued to improve and was discharged from the hospital.
CASE 2
A 62-year-old hypertensive male patient known to have congestive heart failure was admitted to the hospital on December 9th 2011 complaining of abdominal distention and urinary retention. He was transferred to the ICU on December 21st, where he was given meropenem and vancomycin (IV) for 1 week. He started to have severe abdominal distention. A CT scan of the abdomen showed features consistent with toxic megacolon. A stool sample tested positive for C difficile NAP/BI/027. He was treated with metronidazole and vancomycin (oral) for 2 weeks. His condition continued to deteriorate, and he died as a result of C difficile NAP/BI/027 infection.
CASE 3
A 68-year-old hypertensive woman was admitted to the hospital on December 16th 2011 complaining of chest pain and was diagnosed with myocardial infarction. She was admitted to the ICU. The patient underwent coronary artery bypass graft surgery and was treated post-operatively with cefazolin for 2 days. Three days later, the patient began to have diarrhea and vomiting. A stool sample tested positive for C difficile NAP/BI/027. The patient was given metronidazole; she made a full recovery and was discharged.
CASE 4
A 67-year-old male patient known to have large B cell lymphoma was admitted to the hospital with acute exacerbation of COPD. He was treated with ceftriaxone for 2 weeks. Because he continued to have a fever, the antibiotic was changed to a piperacillin/tazobactam regimen that was continued for 5 weeks. During his hospital stay, the patient complained of diarrhea and developed hypotension. A stool sample was positive for C difficile NAP/ BI/027. The patient was treated with metronidazole and vancomycin (oral). He slowly improved and was discharged from the hospital.
To our knowledge, this is the first report of this serious infection in Saudi Arabia. It is likely that previous cases have been overlooked because their diagnosis requires PCR testing, which is not widely available. This report highlights the need for increased laboratory surveillance for this organism and better infection control measures. The aim of these findings is to raise health care workers’ awareness of the existence and importance of this infection.
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