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Title: The epidemiology of Clostridium difficile infection in the community
Author: Oke, Oluwakayode
ISNI:       0000 0004 6352 256X
Awarding Body: University of Nottingham
Current Institution: University of Nottingham
Date of Award: 2014
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Clostridium difficile infection is associated with substantial morbidity and increase in the cost of healthcare. There has been a rise in the incidence of Clostridium difficile infection in the last twenty years globally (although incidence has been on the decline since 2007 in the United Kingdom). A breakdown of the data shows that both community and hospital-associated cases are on the increase in most countries. However the incidence of community-associated Clostridium difficile infection (CA-CDI) in the United Kingdom is unknown: previous estimates are either based on local data or do not conform to standard case definitions. In addition a significant number of CA-CDI remains unexplained and evidence on some risk factors is at best inconclusive. Also, the factors associated outcomes such as hospitalisation and recurrence following CA-CDI difficile has not been previously examined. Aim and objectives The aim of the thesis is to: estimate the incidence of CA-CDI; identify risk factors for CA-CDI; examine potential associations between statins, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) and the risk of CA-CDI; elucidate risk factors for hospitalisation and recurrence following community-onset CA-CDI. Methods The Clinical Practice Research Database linked to the Hospital Episode Statistics data was used for the data analysis (2002 - 2009). Incidence of CA-CDI was estimated using a cohort design. The age-, gender- and deprivation-specific incidence was also estimated. Incidence of non-traditional Clostridium difficile infection (i.e. individuals with no comorbidities, or antibiotics or PPI prescription before diagnosis of CA-CDI) was also estimated. A case control study was used to examine the risk factors for CA-CDI. Potential association between statins, ACE inhibitors, ARBs and CA-CDI was examined with a case control design. While a cohort design was used to explore the risk factors for hospitalisation and recurrence. Results Incidence of CA-CDI as well as non-traditional Clostridium difficile infection (NCACDI) increased during the study period. Incidence increased with age, incidence was higher in females and there was no discernible pattern with deprivation. Antibiotics, proton pump inhibitors, multiple comorbidities, outpatient visit, history of hospital stay were associated with CA-CDI. ACE inhibitor and statins were associated with decreased risk of CA-CDI in a dose-dependent manner (the finding was not consistent when case definition was based on solely toxin codes). Risk factors for primary hospitalisation for Clostridium difficile following CA-CDI were: age, inflammatory bowel disease, concurrent use of antibiotic and proton pump inhibitor. And model comprising of these factors was predictive of the risk of hospitalisation with a concordance statistics of 0.76. Previous hospitalisation was a significant risk factor for recurrence of CA-CDI. Conclusion This study found an increase in the incidence of CA-CDI and NCA-CDI. Though there was a protective effect in those who had statin and ACE inhibitor users, the findings were not consistent and would warrant further investigation. Those at risk of hospitalisation could be identified from the prediction model and may require a different treatment when seen in primary care.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available