Why were molecular studies not considered to classify Clostridium difficile isolates implicated in an outbreak?



Roy A. Wong-McClureI; Leandra Abarca-GómezI; Xiomara Badilla-VargasI; Moraima Guevara-RodríguezII; Antonio Solano-ChinchillaII; Margarita Marchena-PicadoII; Michele O'SheaIII

ISalud Colectiva, Subárea de Epidemiología Caja Costarricense de Seguro Social San José, Costa Rica Email: rwong@ccss.sa.cr
IIHospital Calderón Guardia Caja Costarricense de Seguro Social San José, Costa Rica
IIIUniversity of Arizona College of Medicine Phoenix, Arizona United States of America



To the Editor:

We are pleased that Rodríguez-Cavallini and colleagues have recognized our paper, "Clostridium difficile outbreak in Costa Rica: control actions and associated factors," for broadening the literature on C. difficile associated disease (CDAD) epidemiology and prevention in Latin America (1).

As to the contradiction mentioned with regards to the study results, it is important to consider that a diverse array of antibiotics can be associated with CDAD. Our study results are in agreement with the Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update (2), which includes restriction of antimicrobial use as cephalosporins, with high recommendation strength based on quality of evidence.

For our study, samples were collected from all affected patients rather than from a subset of cases during the outbreak. When comparing our results with those cited in existing literature in Latin America and in Costa Rica, it is important to consider that the local epidemiological profile of C. difficile at other centers may vary considerably from that of the hospital in this study. Also, it should be noted that the main objective of the study was to describe the infection control strategies implemented during the outbreak and to determine factors associated with C. difficile infection. The determination of specific molecular features of C. difficile was not a main focus of the investigation.

Finally, we commend the invaluable effort of the Laboratorio de Investigación en Bacteriología Anaerobia (LIBA) of the University of Costa Rica in contributing to the existing knowledge of autochthonous C. difficile pulsotypes. Given the inherent diversity of Costa Rican health centers, we feel it is extremely important to incorporate the work of LIBA into the country's routine surveillance of C. difficile to increase knowledge regarding this critical pathogen.



1. Wong-McClure RA, Guevara-Rodríguez M, Abarca-Gómez L, Solano-Chinchilla A, Marchena-Picado M, O'Shea M, et al. Clostridium difficile outbreak in Costa Rica: control actions and associated factors. Rev Panam Salud Publica. 2012;32(6): 413–8.         

2. Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, et al. Clinical Practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431–55.         

Organización Panamericana de la Salud Washington - Washington - United States
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