Healthcare-associated Clostridium Difficile Infection Research Articles

Healthcare-Associated Clostridium difficile Infections and Strain Diversity in Pediatric Hospitals in the Canadian Nosocomial Infection Surveillance Program, 2007-2011.

Children with healthcare-associated Clostridium difficile infection were identified. The incidence increased from 3.2/10,000 patient days in 2007 to 5.2/10,000 patient days in 2011 (p < 0.001). Of 169 isolates, the most common North American Pulsed-Field (NAP) types were NAP4 (n = 43; (25.4%), and NAP1 (n = 25;14.8%) while 55 (32.6%) were non-assigned NAP types.

Antimicrobial resistance surveillance in Canadian hospitals, 2007-2012.

The Canadian Nosocomial Infection Surveillance Program (CNISP) is a collaborative effort of the Public Health Agency of Canada's Centre for Communicable Diseases and Infection Control, the National Microbiology Laboratory, and 54 largely university-affiliated tertiary care sentinel hospitals in 10 provinces across Canada. To provide a summary of antibiotic resistance rates of four key antibiotic resistant organisms in major hospitals across Canada from January 1, 2007, to December 31, 2012. Patients' clinical and demographic data and associated results of laboratory analyses were submitted to the Agency by participating hospitals. The infection rates were summarized per 1,000 patient admissions at national and regional levels. In Canada, the overall health care-associated Clostridium difficile infection (HA-CDI), HA-CDI rates peaked in 2008 at 5.8 HA-CDI infections per 1,000 patient admissions then remained stable between 2009 and 2012 at approximately 5 HA-CDI infections per 1,000 admissions; the West and Central regions had higher rates than the Eastern region. The rates of methicillin-resistant Staphylococcus aureus (MRSA) peaked in 2009 at 9.5 MRSA infections per 1,000 patient admissions then decreased to 8.8 MRSA infections per 1,000 admissions in 2012, with the Central region having higher rates than the Western and Eastern regions. The rates of vancomycin-resistant Enterococci (VRE), have been low but rising with 0.08 VRE infections per 1,000 patient admissions in 2007, gradually rising to 0.5 VRE infections per 1,000 admissions in 2012, with consistently higher rates in the Western region, slightly lower rates in the Central region and the lowest rates in the Eastern region. The rates of carbapenem-resistant Enterobacteriaceae (CRE) have been measured since 2010 and have been low and stable, with 0.11 CRE infections per 1,000 patient admissions in 2010 and 0.14 CRE infections per 1,000 admissions in 2012, with higher rates in the Western and Central regions and lower rates in the Eastern region. In Canada, of the four antibiotic resistant organisms under surveillance, HA-CDI and MRSA have been gradually decreasing, VRE is low but rising, and CRE remains low with Western and Central rates consistently higher than Eastern rates.

Evaluation of dedicated infectious diseases pharmacists on antimicrobial stewardship teams.

Patient care improvements and cost savings achieved by a large integrated health system through the implementation of antimicrobial stewardship programs (ASPs) at two hospitals are reported. A pre-post analysis was conducted to evaluate cost and quality outcomes at the two ASP sites and three similar sites within the same health system not included in the ASP initiative. The utilization of 15 targeted antimicrobials and associated costs at the five sites during designated preimplementation and postimplementation periods were compared; changes in Hospital Standardized Mortality Ratio (HSMR) values for specific infections among Medicare patients were also assessed. In the year after ASP implementation, aggregate direct antimicrobial acquisition costs at the two study sites decreased 17.3% from prior-year levels and increased by 9.1% at the three comparator sites. Significant decreases in the consumption of targeted antimicrobial classes (antipseudomonals, quinolones, and agents active against methicillin-resistant Staphylococcus aureus) were observed at the ASP sites. Among the 2446 ASP interventions recorded, 72% involved discontinuing or narrowing the use of broad-spectrum antimicrobials. Although rates of health care-associated Clostridium difficile infection were little changed at both study sites after ASP implementation, HSMR data indicated substantial gains in combating sepsis and C. difficile and respiratory infections. After implementation of ASPs at two study sites, the utilization of all classes of antibiotics decreased and antimicrobial costs per 1000 patient-days decreased. While HSMR values for sepsis (including C. difficile-associated cases) and respiratory infections improved, the rate of C. difficile infections stayed the same.

Testing for Clostridium Difficile: A Perspective Approach

Clostridium difficile Infection (CDI) presents a significant threat to the health and well-being of those who acquire this disease globally. Active infection with a toxigenic strain presents with symptoms ranging from mild illness to severe fulminant disease. The incidence and severity of illness have significantly increased since the emergence of a hypervirulent toxigenic strain of C difficile discovered in Canada and the United States at the turn of the century. With its spread and high level of communicability, the healthcare industry is faced with many challenges in the attempt to minimize and prevent healthcare-associated CDI.

Storage duration of red blood cell transfusion and Clostridium difficile infection: a within person comparison.

ObjectiveRandomized controlled trials demonstrated that red blood cell (RBC) transfusion elevates the risk of infection, and trials are underway to evaluate whether RBC storage affects outcomes. We previously reported that transfusion predicts Clostridium difficile infection (CDI) and, therefore, planned an investigation to examine this further using a more robust design.DesignWithin-person case-crossover study. Hospitalizations in which CDI developed (n = 406) were compared to hospitalizations for the same individuals in which CDI did not occur (n = 949). Transfusion volume and storage duration were assessed prior to the onset of CDI.SettingUniversity of Michigan Health System.PatientsParticipants were individuals with a diagnosis of CDI from July 2009 through June 2012.Measurements and Main ResultsDuring the hospitalizations when CDI occurred, 34.7% of the patients received allogeneic RBC transfusions (mean volume, 688 ml) compared to 19.0% of patients in hospitalizations without CDI (mean volume, 180 ml). The odds of healthcare-associated CDI increased by 76% (95% CI 1.39–2.23) for every liter of RBCs transfused and was elevated in both nonsurgical (OR = 1.90) and surgical (OR = 1.86) hospitalizations. In patients who received RBC transfusions, the odds of developing CDI increased by 6% for every additional day of RBC stored and by 53% for every week of additional storage (P = 0.002).ConclusionsHospitalizations in which a patient received a greater volume of RBC transfusions were more likely to be associated with the development of CDI. RBC units stored for a longer duration were associated with the development of healthcare-associated CDI after adjustment for RBC volume.

Medication risk factors associated with healthcare-associated Clostridium difficile infection: a multilevel model case-control study among 64 US academic medical centres

The main objective of this study was to determine patient- and hospital-level medication risk factors associated with Clostridium difficile infection (CDI) occurrence among patients clustered within hospitals using a multilevel model. Patients with healthcare-associated (HA)-CDI were identified from among 64 academic medical centres in 2009. A frequency match was conducted; for each case, up to two controls were selected, matched on similar pre-infection length of stay and clinical service line. Patient- and hospital-level medication use, including antibacterial and gastric acid-suppressant agents, was assessed using a two-level logistic regression model. A total of 5967 CDI cases and 8167 controls were included in the analysis. The odds of acquiring HA-CDI increased with the following medications [OR (95% CI)]: anti-methicillin-resistant Staphylococcus aureus agents [1.38 (1.22-1.56)]; third- or fourth-generation cephalosporins [1.75 (1.62-1.89)]; carbapenems [1.60 (1.44-1.79)]; β-lactam/β-lactamase inhibitor combinations [1.49 (1.36-1.64)]; vancomycin [1.73 (1.57-1.89)]; and proton pump inhibitors [1.43 (1.30-1.57)]. The odds of acquiring HA-CDI decreased with the following medications: clindamycin [0.74 (0.63-0.87)]; and macrolides [0.88 (0.77-0.99)]. Controlling for patient-level covariates, no hospital-level medication covariates that we analysed had statistically significant effects on HA-CDI. The odds of acquiring HA-CDI increased with the hospital proportion of patients aged ≥ 65 years [1.01 (1.00-1.02)]. We found several medications that were associated with the risk of patients developing HA-CDI, including β-lactam/β-lactamase inhibitor combinations, third- or fourth-generation cephalosporins, carbapenems, vancomycin, proton pump inhibitors and anti-methicillin-resistant S. aureus agents. There were no medication effects significant at the hospital level.

The prolongation of length of stay because of Clostridium difficile infection

Clostridium difficile infection (CDI) possibly extends hospital length of stay (LOS); however, the current evidence does not account for the time-dependent bias, ie, when infection is incorrectly analyzed as a baseline covariate. The aim of this study was to determine whether CDI increases LOS after managing this bias. We examined the estimated extra LOS because of CDI using a multistate model. Data from all persons hospitalized >48 hours over 4 years in a tertiary hospital in Australia were analyzed. Persons with health care-associated CDIs were identified. Cox proportional hazards models were applied together with multistate modeling. One hundred fifty-eight of 58,942 admissions examined had CDI. The mean extra LOS because of infection was 0.9 days (95% confidence interval: -1.8 to 3.6 days, P = .51) when a multistate model was applied. The hazard of discharge was lower in persons who had CDI (adjusted hazard ratio, 0.42; P < .001) when a Cox proportional hazard model was applied. This study is the first to use multistate models to determine the extra LOS because of CDI. Results suggest CDI does not significantly contribute to hospital LOS, contradicting findings published elsewhere. Conversely, when methods prone to result in time-dependent bias were applied to the data, the hazard of discharge significantly increased. These findings contribute to discussion on methods used to evaluate LOS and health care-associated infections.

Reducing Clostridium difficile Incidence, Colectomies, and Mortality in the Hospital Setting: A Successful Multidisciplinary Approach

Health care associated Clostridium difficile infections are a major cause of morbidity and mortality in hospitals. In the United States, from 2000 through 2009, discharge diagnoses from hospitals in the United States that included C. difficile increased from 139,000 to 336,600, and the yearly national excess hospital cost associated with hospital-onset C. difficile is estimated to be upwards of $1.3 billion. A hospitalwide, multidisciplinary approach was undertaken at Rhode Island Hospital (Providence), a tertiary care hospital. The hospital plan entailed six interventions: (1) develop a C. difficile hospital infection control plan based on a risk assessment; (2) monitor hospitalwide morbidity and mortality associated with C. difficile infection; (3) improve sensitivity of C. difficile toxin detection in stool specimens using a polymerase chain reaction-based nucleic acid amplification assay; (4) enhance environmental cleaning of patient rooms and equipment; (5) develop a C. difficile infection treatment plan; and (6) conduct other interventions. The incidence of health care-associated C. difficile infection was assessed from January 2006 through the third quarter of 2012; the number of colectomies and mortality associated with C. difficile infection were determined from January 2005 through the third quarter of 2012. The incidence of health care-associated C. difficile infection decreased from a peak of 12.2/1,000 discharges during the second quarter of 2006 to 3.6/1,000 discharges during the third quarter of 2012. The yearly mortality in patients with health care-associated C. difficile infection was reduced from a peak of 52 in 2006 to 19 in 2011, with 13 such cases in the first three quarters of 2012. A hospitalwide multidisciplinary approach can reduce health care-associated C. difficile infection morbidity and mortality.

Epidemiology of Clostridium difficile infections in a tertiary-care hospital in Korea

To survey healthcare-associated Clostridium difficile infection (HA-CDI) in a 900-bed tertiary-care hospital, we prospectively investigated the epidemiology of CDI and distribution of PCR-ribotypes. From February 2009 through January 2010, all patients with HA-CDI were enrolled. Epidemiological information and prescription records for antibiotics were collected. The C. difficile isolates were characterized using reference strains and were tested for antibiotic susceptibility. During the survey, incidence of HA-CDI was 71.6 per 100 000 patient-days. In total, 140 C. difficile isolates were obtained from 166 patients with HA-CDI. The PCR-ribotyping yielded 38 distinct ribotypes. The three most frequently found ribotypes made up 56.4% of all isolates; they comprised 37 isolates (26.4%) of PCR-ribotype 018, 22 (15.7%) of toxin A-negative PCR-ribotype 017, and 20 (14.3%) of PCR-ribotype 001. Clostridium difficile PCR-ribotype 018 was present in all departments throughout the hospital during the 11 months, whereas ribotype 017 and ribotype 001 appeared mostly in the pulmonary department. Hypervirulent C. difficile PCR-ribotype 027 was detected in 1 month on two wards. The incidence of CDI in each department showed a seven-fold difference, which correlated significantly with the amount of prescribed clindamycin (R = 0.783, p 0.013) or moxifloxacin (R = 0.733, p 0.025) in the departments. The rates of resistance of the three commonest ribotypes to clindamycin and moxifloxacin were significantly higher than those of other strains (92.1% versus 38.2% and 89.5% versus 27.3%, respectively). CDI is an important nosocomially acquired infection and this study emphasizes the importance of implementing country-wide surveillance to detect and control CDI in Korea.

Sustainment of a Multidisciplinary Approach to Decrease Healthcare-associated Clostridium-difficile Infections

Clostridium difficile infection (CDI) is a significant healthcare burden and is related to increased hospital costs, length of stay, morbidity and mortality. CDI surveillance facilitates early identification, interventions to prevent transmission, and monitoring of adherence to prevention practices.

Impact of the Type of Diagnostic Assay on Clostridium difficile Infection and Complication Rates in a Mandatory Reporting Program

Most Clostridium difficile infection (CDI) surveillance programs neither specify the diagnostic method to be used nor stratify rates accordingly. We assessed the difference in healthcare-associated CDI (HA-CDI) incidence and complication rates obtained by 2 validated diagnostic methods. This was a prospective cohort study of patients for whom a C. difficile test was ordered between 1 August 2010 and 31 July 2011. All specimens were tested in parallel by a commercial polymerase chain reaction (PCR) assay targeting toxin B gene tcdB, and a 3-step algorithm detecting glutamate dehydrogenase and toxins A and B by enzyme immunoassay and cell culture cytotoxicity assay (EIA/CCA). CDI incidence rate ratios were calculated using univariate Poisson regression. A total of 1321 stool samples were tested during a period totaling 95 750 patient-days. Eighty-five HA-CDI cases were detected by PCR and 56 cases by EIA/CCA (P = .01). The overall incidence rate was 8.9 per 10 000 patient-days (95% confidence interval [CI], 7.1-10.9) by PCR and 5.8 per 10 000 patient-days (95% CI, 4.4-7.4) by EIA/CCA (P = .01). The incidence rate ratio comparing PCR and EIA/CCA was 1.52 (95% CI, 1.08-2.13; P = .015). Overall complication rate was 27% (23/85) when CDI was diagnosed by PCR and 39% (22/56) by EIA/CCA (P = .16). Cases detected by PCR only were less likely to develop a complication of CDI compared with cases detected by both PCR and EIA/CCA (3% vs 39%, respectively; P < .001). Performing PCR instead of EIA/CCA is associated with a >50% increase in the CDI incidence rate. Standardization of diagnostic methods may be indicated to improve interhospital comparison.

Editorial Commentary: Deconstructing the Veterans Affairs MRSA Prevention Bundle

During the 1970s and 1980s, methicillinresistant Staphylococcus aureus (MRSA) became endemic in hospitals worldwide [1]. By 2007, a large-scale epidemiological study determined that 94 000 cases of invasive MRSA disease and 19 000 MRSA-related in-hospital deaths occurred annually in the United States [2]. Using these estimates, an editorial suggested that the burden of MRSA deaths exceeded that of deaths due to human immunodeficiency virus or AIDS in the United States [3]. TheoptimalapproachtoMRSAprevention in hospital settings is debated [4, 5]. In general, 2 epidemiological approaches have been described: (1) “horizontal” programs that broadly attempt to reduce infections from all pathogens and (2) “vertical” programs that aim to eradicate a single pathogen [6]. Horizontal programs include hand hygiene improvement interventions and centralline association bloodstream infection (CLABSI) “bundles.” Vertical programs screen all or selected patients for MRSA colonization by obtaining a nares swab sample and place MRSA-colonized or MRSA-infected patients on contact precautions. Contact precautions include single-bed rooms and patient cohorting and require healthcare workers to wear gowns and gloves for all contacts. Some studies reported benefits of such screening programs [7], some reported benefits when screening was combined with decolonization [8], and some found screening and isolation to be ineffective [9, 10]. After a successful pilot study in the VA Pittsburgh Healthcare System, in August 2006 the Veterans Health Administration implemented a MRSA bundle in 17 US Department of Veterans Affairs (VA) medical centers [11]. The bundle included (1) admission, inhospital transfer, and discharge activesurveillance swab samples for MRSA; (2) contact precautions for patients known or found to be MRSA carriers; (3) efforts targeting improved hand hygiene; and (4) efforts encouraging culture change [12]. Importantly, and infrequently, mentioned in descriptions of the VA MRSA Initiative, support was also made available for a MRSA prevention coordinator at each site, who was responsible for coordinating implementation of the bundle. Thus, the VA bundle included 1 vertical intervention (swab samples and contact precautions) and 3 horizontal interventions (hand hygiene, culture change, and MRSA prevention coordinator). By October 2007 the bundle was implemented in all acute-care (except mental health) units in 150 of 153 VA medical centers. By most measures the VA MRSA Initiative was a success. From initiation to June 2010, healthcare-associated MRSA infections declined by 62% in intensive care units (ICUs) and by 45% in nonICUs. MRSA acquisition declined 17% in ICUs and 21% in non-ICU settings. Interestingly, a subset of hospitals reported healthcare-associated vancomycin-resistant enterococcal and Clostridium difficile infection rates. After the initiative, vancomycin-resistant enterococcal infections were eliminated in ICUs and declined by 73% in non-ICUs. C. difficile infections declined 61% in non-ICU settings, with no change in ICUs [12]. How do we explain the MRSA declines reported by the VA? A nationwide decline in MRSA seen during the study period [13] might have contributed to these in-hospital declines; however, MRSA positivity on admission was relatively flat during the study period, so any outside impact should have been negligible. Importantly, infections declined 2–3 times more than incident colonization, suggesting that factors other than surveillance swab samples and isolation played a role in reduced MRSA infections. Thus, it seems that one benefit of the bundle was to reduce Received 22 February 2012; accepted 24 February 2012; electronically published 4 April 2012. Correspondence: Eli N. Perencevich, MD, MS, CADRE, Iowa City VA Medical Center, 601 Hwy 6 W, Iowa City, IA 52246 (eli-perencevich@uiowa.edu). Clinical Infectious Diseases 2012;54(11):1621–3 © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. DOI: 10.1093/cid/cis277

Economic Impact of Clostridium difficile Infection in a Multihospital Cohort of Academic Health Centers

To assess the economic impact of Clostridium difficile infection (CDI) in a large multihospital cohort. Retrospective case-control study. Administrative claims data from 45 academic medical centers. A total of 10,857 patients who developed health care-associated CDI and were discharged between April 1, 2002, and March 31, 2007 (cases); each case patient was matched by hospital, age, quarter and year of hospital discharge, and diagnosis related group to at least one control patient who did not develop health care-associated CDI (19,214 controls). Patients with health care-associated CDI were identified by using a previously validated method combining the International Classification of Diseases, Ninth Revision, Clinical Modification code for CDI with specific CDI drug therapy (oral or intravenous metronidazole, or oral vancomycin). Costs were determined from charges by using standardized cost:charges ratios and were adjusted for age, All Patient Refined-Diagnosis Related Group (APR-DRG) severity of illness level, race, and sex with use of multivariable linear regression. The adjusted mean cost for cases was significantly higher than that for controls ($55,769 vs $28,609), and adjusted mean length of stay was twice as long (21.1 vs 10.0 days). The interaction between CDI and APR-DRG severity of illness level was significant; the effect of CDI on costs and length of stay decreased as severity of illness increased. This large CDI economic evaluation confirms that health care-associated cases of CDI are associated with significantly higher mean cost and longer length of stay than those of matched controls, with the greatest effect on costs at the lowest level of severity of illness.

Continuing Medical Education: November 2010

Prevention of Endemic Healthcare-Associated Clostridium difficile Infection: Reviewing the Evidence The American College of Gastroenterology is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The American College of Gastroenterology designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Prevention of Endemic Healthcare-Associated Clostridium difficile Infection: Reviewing the Evidence

Clostridium difficile is the most common infectious cause of healthcare-associated diarrhea. Because of the increasing incidence and severity of endemic C. difficile infection (CDI), interventions to prevent healthcare-associated CDI are essential. We undertook a systematic review of interventions to reduce healthcare-associated CDI. We searched multiple computerized databases, and manually searched for relevant articles to determine which interventions are useful in preventing CDI. Studies were required to be controlled in design and to report the incidence of endemic CDI as an outcome. Data on the patient population, intervention, study design, and outcomes were abstracted and reviewed using established criteria. Few randomized controlled trials exist in the area of CDI prevention. The interventions with the greatest evidence for the prevention of CDI include antimicrobial stewardship, glove use, and disposable thermometers. Environmental decontamination also may decrease CDI rates, although the level of evidence is not as strong as for the other proven interventions. Treatment of asymptomatic carriage of C. difficile is not recommended. There is insufficient evidence to make a recommendation for or against the use of probiotics. In cases of known or suspected CDI, hand hygiene with soap and water is preferred over use of waterless alcohol hand rub. Many nonrandomized trials included in our analysis used multiple interventions concurrently, making the independent role of each preventive strategy difficult to determine. We chose to include only studies that focused on endemic CDI because studies of outbreaks have used multiple strategies, making it difficult to measure the relative efficacy of each strategy. Environmental disinfection and probiotics need to be studied further to evaluate their roles in the prevention of CDI. Although there have been no studies assessing the utility of isolation and cohorting for the prevention of endemic CDI specifically, it is a widely used intervention for containment of this and other similar multidrug-resistant pathogens. Antimicrobial stewardship, glove use, hand hygiene, and disposable thermometers should be routinely used for the prevention of CDI. Environmental disinfection and probiotics should be studied further for their role in reducing CDI.

Proposed Checklist of Hospital Interventions to Decrease the Incidence of Healthcare-Associated Clostridium difficile Infection

The incidence and severity of Clostridium difficile infection (CDI) are increasing, and previously described interventions for controlling the spread of CDI are not easily generalized to multiple healthcare institutions. We tested prevention and treatment bundles to decrease the incidence of CDI and the mortality associated with CDI at our hospital. Observational before-after study of adult patients admitted to a tertiary care, university-affiliated hospital during the period from January 2004 through December 2008. In January 2006, we launched an educational campaign and introduced a prevention bundle-a series of specific processes aimed at preventing the transmission of C. difficile among hospitalized patients, including enhanced isolation practices, laboratory notification procedures, and steps coordinating infection control and environmental services activities. In April 2006, we implemented a treatment bundle-a set of hospital-wide treatment practices aimed at minimizing the risk of serious CDI complications. We tracked quarterly incidence rates and case-fatality rates for healthcare-associated CDI cases at our hospital. Our main outcome was the healthcare-associated CDI incidence rate, measured as the number of healthcare-associated cases of CDI per 1,000 patient-days. We followed patients for a total of 1,047,849 patient-days. The healthcare-associated CDI incidence rates fell from an average of 1.10 cases per 1,000 patient-days before intervention to 0.66 cases per 1,000 patient-days after intervention. This statistically significant decrease amounts to a 40% reduction in incidence after the intervention. Our intervention was successful in reducing the incidence of CDI at our hospital. On the basis of our experience, we propose the use of a checklist of hospital interventions to decrease the incidence of healthcare-associated CDI.

Implementation of Disposable Blood Pressure Cuffs as a Novel Approach to Reduce Fomite Transmission of Healthcare-Associated (HCA) Clostridium difficile Infection (CDI) in a Community Hospital or Twice Implemented is Once Credible

Implementation of Disposable Blood Pressure Cuffs as a Novel Approach to Reduce Fomite Transmission of Healthcare-Associated (HCA) Clostridium difficile Infection (CDI) in a Community Hospital or Twice Implemented is Once Credible

National point prevalence of Clostridium difficile in US health care facility inpatients, 2008

Recent published estimates of Clostridium difficile infection (CDI) incidence have been based on small numbers of hospitals or national hospital discharge data. These data suggest that CDI incidence is increasing. We conducted a point prevalence survey of C difficile in inpatients at US health care facilities. The survey was developed, received Institutional Review Board approval, and was then distributed to all Association for Professionals in Infection Control and Epidemiology, Inc (APIC) members. They were asked to complete the survey on 1 day between May 7 and August 29, 2008, reporting the number of inpatients with CDI or colonization and facility-specific information. Personnel at 648 hospitals completed the survey; this represents approximately 12.5% of all US acute care facilities. All but 3 states and the District of Columbia were represented (mean, 14 facilities per state; range, 2-43). Eighty-two percent reported that their CDI rate had not decreased in the past 3 years. Respondents reported 1443 C difficile-colonized/infected patients among 110,550 inpatients; the overall C difficile prevalence rate was 13.1 per 1000 inpatients (94.4% infection). Detailed data were provided on 1062 (73.6%) patients. Of these, 55.5% were female, 69.2% were >60 years of age, 67.6% had selected comorbid conditions, 79% had received antimicrobials within 30 days, and 94.4% were detected by enzyme immunoassay. The majority of patients (54.4%) were diagnosed < or =48 hours of hospitalization, but 35% had been admitted to a long-term care facility within 30 days, and 47% had been hospitalized within 90 days; 73% met Centers for Disease Control and Prevention criteria for health care-associated CDI. Most facilities (>90%) used contact isolation for CDI patients. Bleach was used for environmental disinfection more commonly during CDI outbreaks than during nonoutbreak periods. Our survey documents a higher C difficile prevalence rate than previous estimates using different methodologies. The majority of inpatient CDI appears to be health care associated. Given that not all patients with diarrhea are tested for CDI and that most facilities use enzyme immunoassays with limited sensitivity to detect C difficile, these are minimum estimates of the US health care facility C difficile burden.

Health Care–Associated Clostridium difficile Infection in Adults Admitted to Acute Care Hospitals in Canada: A Canadian Nosocomial Infection Surveillance Program Study

Health Care–Associated Clostridium difficile Infection in Adults Admitted to Acute Care Hospitals in Canada: A Canadian Nosocomial Infection Surveillance Program Study

P765 Co-existence of Clostridium difficile and vancomycin-resistant enterococci in stool samples, in a tertiary hospital in Greece, during a one-year period

To survey healthcare-associated Clostridium difficile infection (HA-CDI) in a 900-bed tertiary-care hospital, we prospectively investigated the epidemiology of CDI and distribution of PCR-ribotypes. From February 2009 through January 2010, all patients with HA-CDI were enrolled. Epidemiological information and prescription records for antibiotics were collected. The C. difficile isolates were characterized using reference strains and were tested for antibiotic susceptibility. During the survey, incidence of HA-CDI was 71.6 per 100 000 patient-days. In total, 140 C. difficile isolates were obtained from 166 patients with HA-CDI. The PCR-ribotyping yielded 38 distinct ribotypes. The three most frequently found ribotypes made up 56.4% of all isolates; they comprised 37 isolates (26.4%) of PCR-ribotype 018, 22 (15.7%) of toxin A-negative PCR-ribotype 017, and 20 (14.3%) of PCR-ribotype 001. Clostridium difficile PCR-ribotype 018 was present in all departments throughout the hospital during the 11 months, whereas ribotype 017 and ribotype 001 appeared mostly in the pulmonary department. Hypervirulent C. difficile PCR-ribotype 027 was detected in 1 month on two wards. The incidence of CDI in each department showed a seven-fold difference, which correlated significantly with the amount of prescribed clindamycin (R = 0.783, p 0.013) or moxifloxacin (R = 0.733, p 0.025) in the departments. The rates of resistance of the three commonest ribotypes to clindamycin and moxifloxacin were significantly higher than those of other strains (92.1% versus 38.2% and 89.5% versus 27.3%, respectively). CDI is an important nosocomially acquired infection and this study emphasizes the importance of implementing country-wide surveillance to detect and control CDI in Korea.