Abstract
To quantify the effect of hospital and community-based transmission and control measures on Clostridium difficile infection (CDI), we constructed a transmission model within and between hospital, community, and long-term care-facility settings. By parameterizing the model from national databases and calibrating it to C. difficile prevalence and CDI incidence, we found that hospitalized patients with CDI transmit C. difficile at a rate 15 (95% CI 7.2-32) times that of asymptomatic patients. Long-term care facility residents transmit at a rate of 27% (95% CI 13%-51%) that of hospitalized patients, and persons in the community at a rate of 0.1% (95% CI 0.062%-0.2%) that of hospitalized patients. Despite lower transmission rates for asymptomatic carriers and community sources, these transmission routes have a substantial effect on hospital-onset CDI because of the larger reservoir of hospitalized carriers and persons in the community. Asymptomatic carriers and community sources should be accounted for when designing and evaluating control interventions.
Highlights
To quantify the effect of hospital and community-based transmission and control measures on Clostridium difficile infection (CDI), we constructed a transmission model within and between hospital, community, and long-term care-facility settings
We calculated that an uncolonized person in the hospital has a probability of 2.3% per day of acquiring C. difficile and becoming a carrier; an uncolonized person in the community has a probability of 0.12% per day, and a person in an long-term care facilities (LTCFs) has a probability of 0.37% per day (Table 2)
We estimated that for every unit increase in antimicrobial drug risk ratio, the CDI incidence increased by 160% in the hospital, 33% in the LTCF, and 6.4% in the community. These results indicate that the effect of antimicrobial drug risk on CDI incidence is intertwined with C. difficile transmission dynamics, which differ between the hospital, LTCF, and community
Summary
To quantify the effect of hospital and community-based transmission and control measures on Clostridium difficile infection (CDI), we constructed a transmission model within and between hospital, community, and long-term care-facility settings. Molecular typing and contact tracing studies have estimated that 10%–38% of CDI cases that occur >48 hours after hospital admission (termed hospital-onset CDI) can be attributed to transmission from known symptomatic contacts within the hospital [3,4,5,6] These estimates suggest that a substantial proportion of CDI arises from other sources, such as transmission from patients with asymptomatic colonization or community acquisition [3,5,7,8]. Mathematical models of C. difficile colonization have generated insights regarding the epidemiologic role of antimicrobial drugs on CDI outbreaks [10] Such models have quantified the effect of hospital-based control interventions [11,12,13,14] and demonstrated the crucial roles of asymptomatic colonization and patients with exposure before hospital admission in sustaining hospital transmission [7,13]. To fully understand the epidemiology of the pathogen and to inform decisions regarding control strategies, it is crucial to quantify the relative transmission of C. difficile in the hospital and in the broader community [8]
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