Clostridioides difficile infections in seven Brazilian hospitals during the COVID-19 pandemic: hand hygiene and antimicrobial consumption

Gonçalves, Luiza Arcas; Santos, Ivan Lira dos; Porto, Ana Paula Matos; Viana Junior, Antônio Brazil; Carijo, Julia Herkenhoff; Carillho, Claudia Dantas de Maio; Cocentino, Brunno Cesar Batista; Passos, Luciana Neves; Varkulja, Glaucia Fernanda; Guimarães, Thais; Costa, Silvia Figueiredo

doi:10.1590/S1678-9946202668031

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Sumário

ORIGINAL ARTICLE • Rev. Inst. Med. trop. S. Paulo 68 • 2026 • https://doi.org/10.1590/S1678-9946202668031 linkcopy

Clostridioides difficile infections in seven Brazilian hospitals during the COVID-19 pandemic: hand hygiene and antimicrobial consumption

Authorship SCIMAGO INSTITUTIONS RANKINGS

This study aimed to evaluate the incidence density of Clostridioides difficile infections (CDIs), hand hygiene adherence, and antimicrobial consumption across Brazilian hospitals during the COVID-19 pandemic. An ecological study was conducted in seven Brazilian hospitals from June 2018 to December 2019 (pre-pandemic) and from June 2020 to December 2021(pandemic). Data on CDI incidence density, hand hygiene adherence, and antimicrobial consumption were collected. CDI incidence was assessed based on the number of monthly cases and the incidence density rate per 10,000 patient-days. This study involved hospitals from four states and included three public and four private institutions. Statistical analyses were performed using the Mann-Whitney U test in R (p < 0.05). Time series analysis used joinpoint regression to determine monthly percent change, average monthly percent change, and 95% confidence intervals. Although statistically insignificant, an upward trend occurred in CDI incidence (p = 0.081) from the pre-pandemic to the pandemic periods. Consumption of azithromycin (p < 0.01) and levofloxacin (p < 0.01) increased significantly, whereas ceftriaxone use decreased (p = 0.0038). The joinpoint regression analysis of antimicrobial consumption trends during the pandemic showed trend changes for vancomycin and meropenem defined daily dose, with higher consumption during the second wave of COVID-19 in Brazil. Hand hygiene adherence failed to differ significantly but showed a downward trend in 2020 and 2021. The dynamics of the COVID-19 pandemic and changes in protective measures may have influenced CDI incidence and antimicrobial consumption patterns across the study period.

Clostridioides difficile; COVID-19; Antibiotic consumption

	A (N=19^a)	B (N=38^a)	C (N=38^a)	D (N=38^a)	E (N=38^a)	F (N=38^a)	G (N=38^a)
CDI incidence density (per 10.000 patient-day)	0.00 (0.00–2.62)	1.17 (0.56–2.33)	1.58 (1.32–2.52)	0.00 (0.00–2.78)	1.45 (0.00–2.78)	0.00 (0.00–1.22)	5.17 (2.41–8.22)
CDI cases	0.00 (0.00–0.50)	2.00 (1.00–4.00)	3.00 (2.00–4.00)	0.00 (0.00–1.00)	1.00 (0.00–2.00)	0.00 (0.00–1.00)	2.00 (1.00–3.00)
Hospital beds	97 (97–97)	874 (795–910)	714 (712–715)	145 (145–145)	316 (316–342)	378 (363–393)	184 (184–184)
Total admissions	472 (373–504)	2,380 (1,686–2,707)	2,094 (1,884–2,650)	902 (808–949)	2,558 (1,860–3,411)	1,429 (1,306–1,489)	1,464 (1,279–1,668)
ICU admissions	114 (94–159)	393 (360–502)	358 (285–424)	134 (114–158)	1,524 (1,440–1,714)	243 (128–290)	256 (236–286)
COVID-19 admissions	29 (13–62)	520 (270–752)	233 (207–233)	10 (5–19)	215 (90–260)	393 (265–486)	111 (56–185)
Hospital patient-days	1,688 (1,222–1,948)	16,714 (14,206–17,775)	15,808 (14,825–18,090)	3,577 (3,429–3,810)	7,152 (6,846–7,607)	8,440 (7,795–9,504)	4,201 (3,904–4,445)
ICU patient-days	795 (568–988)	2,878 (2,760–3,349)	1,570 (1,476–1,732)	452 (411–495)	1,898 (1,774–2,038)	783 (747–2,083)	1,220 (1,087–1,310)
Hand hygiene compliance	0.61 (0.56–0.74)	0.55 (0.43–0.65)	NA (NA–NA)	0.84 (0.83–0.86)	0.83 (0.77–0.86)	NA (NA–NA)	0.77 (0.62–0.84)
DDD (g per 1,000 patient-days)
Clindamycin	NA (NA–NA)	NA (NA–NA)	NA (NA–NA)	NA (NA–NA)	13 (9–21)	NA (NA–NA)	16 (13–22)
Azithromycin	NA (NA–NA)	NA (NA–NA)	NA (NA–NA)	NA (NA–NA)	2 (0–7)	NA (NA–NA)	14 (8–35)
Ceftriaxone	60 (39–72)	116 (80–144)	142 (118–180)	174 (151–214)	134 (110–166)	90 (72–122)	114 (95–134)
Levofloxacin	76 (39–95)	17 (10–24)	3 (0–19)	4 (0–12)	13 (6–20)	62 (47–86)	8 (0–30)
Meropenem	231 (199–280)	132 (110–155)	223 (179–290)	108 (81–146)	118 (103–152)	382 (301–432)	148 (132–188)
Piperacilin-tazobactam	124 (103–170)	62 (43–83)	158 (109–174)	215 (174–275)	64 (56–77)	155 (114–194)	78 (58–104)
Vancomycin	54 (38–80)	93 (82–117)	208 (189–241)	87 (74–111)	38 (30–45)	223 (180–274)	92 (70–102)
Stewardship program
Yes	19 (100%)	38 (100%)	38 (100%)	38 (100%)	19 (50%)	38 (100%)	0 (0%)
No	0 (0%)	0 (0%)	0 (0%)	0 (0%)	19 (50%)	0 (0%)	38 (100%)
Period
Pre-pandemic	0 (0%)	19 (50%)	19 (50%)	19 (50%)	19 (50%)	19 (50%)	19 (50%)
Pandemic	19 (100%)	19 (50%)	19 (50%)	19 (50%)	19 (50%)	19 (50%)	19 (50%)

	COVID-19 Pandemic
	No	Yes	p-value^b
N	114 ^a	114 ^a
CDI incidence
Total	1.40 (0.00–2.71)	1.74 (0.00–3.05)	0.2
Public	1.15 (0,00–2.14)	1.35 (0.57–2.18)	0.3
Private	1.57 (0.00–3.14)	2.69 (0.00–4.08)	0.4
Patients-days	7456 (4520–17106)	7849 (3904–13918)	0.037
Admissions
Total	2040 (1422–2762)	1528 (1167–1830)	<0.001
ICU	356 (196–440)	287 (226–502)	0.7
*Stewardship program*			0.004
No	19 (17%)	38 (33%)
Yes	95 (83%)	76 (67%)
Hand hygiene	0.78 (0.52–0.85)	0.65 (0.56–0.78)	0.084
DDD
Clindamycin	16 (11–26)	13 (9–18)	0.068
Azithromycin	0 (0–2)	8 (5–20)	<0.001
Ceftriaxone	138 (103–166)	123 (92–152)	0.0038
Levofloxacin	9 (1–20)	19 (8–46)	<0.001
Meropenem	152 (118–192)	168 (109–271)	0.6
Piperacillin-tazobactam	88 (60–205)	105 (78–144)	0.6
Vancomycin	91 (63–188)	114 (71–185)	0.3

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Instituto de Medicina Tropical de São Paulo Av. Dr. Enéas de Carvalho Aguiar, 470, 05403-000 - São Paulo - SP - Brazil, Tel. +55 11 3061-7005 - São Paulo - SP - Brazil
E-mail: revimtsp@usp.br

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[TFN1] ^aMedian (IQR); n (%); CDI = Clostridioides difficile infection; ICU = Intensive care unit; DDD = Defined daily doses.