Hospital-associated Clostridium Difficile Infection Research Articles

Hospital-associated Clostridium difficile infection and reservoirs within the hospital environment

Clostridium difficile infection (CDI) is a leading cause of hospital-associated infections. Antibiotic stewardship, environmental disinfection, and reduction of transmission via health care workers are the major modes of CDI prevention within hospitals. The aim of this study was to evaluate the role of the environment in the spread of CDI within hospital rooms. Bed tracing of positive-CDI inpatients was performed to detect the strength of association to specific rooms. Environmental cultures were conducted to identify adequacy of environmental C difficile (CD) spores. Whole-genome sequencing was performed to evaluate the degree of CD relatedness. Bed tracing performed for 211 CDI patients showed a limited list of high-burden rooms. Environmental cultures for surfaces disinfected with a sporicidal agent were almost entirely negative, whereas the floors were positive for CDI in 15% of the studied patient rooms. Whole-genome sequencing did not detect any close genetic relatedness. Unlike in an outbreak setting, bed tracing did not yield conclusive results of room reservoirs. The C diff Banana Broth culture was inexpensive, sensitive, and easy to incubate under aerobic conditions. Sporicidal disinfectants were effective in eliminating CD from the environment. CD spores were found on floors and hard-to-clean surfaces.

Developing an antimicrobial stewardship program across a rural health system: The Avera Health experience.

The stages of development of a health system-wide antimicrobial stewardship program (ASP) using existing personnel and technology are described. Small hospitals with limited resources may struggle to meet ASP requirements, particularly facilities without onsite infectious disease physicians and/or experienced infectious disease pharmacists. Strategies for ASP development employed by Avera Health, a 33-hospital health system in the Midwest, included identifying relevant drug utilization and resistance patterns, education and pathway development, and implementation of Web-based conferencing to provide pharmacists throughout the system with access to infectious disease expertise on a daily basis. These efforts resulted in an evolving single-system ASP that has leveraged existing resources to overcome some system barriers. Program outcomes to date include a reduction in the use of a targeted agent, improved pathogen susceptibility trends, and rates of hospital-associated Clostridium difficile infection below national benchmarks. The Avera Health ASP grew from a collaborative project targeting levofloxacin overuse and resistance among key bacteria to a formal, health system-wide ASP in a rural setting. This program used existing personnel to provide standardized processes, educational campaigns, and antimicrobial expertise through the use of technology. This ASP program may provide helpful examples of ASP strategies for other rural health systems with similar resources.

Role of Antimicrobial Stewardship Programs in Decreasing Hospital-Associated Clostridium difficile Infections

To provide a review of literature that discusses some of the most successful antimicrobial stewardship interventions reported across institutions worldwide in response to increased Clostridium difficile infection (CDI) rates. Although many different types of antimicrobial reduction practices have been proven effective, differences in resources across varying sizes of institutions may make some interventions more attainable than other. Regardless of available resources, an initial assessment of the correlation of positive laboratory tests to clinical disease is necessary to quantify the true burden of hospital-onset CDIs (HO-CDI). Infection prevention programs, in conjunction with antimicrobial reduction interventions, and the appropriate identification of patients to undergo laboratory testing, are key components of a HO-CDI reduction program. Clostridium difficile is an important cause of serious healthcare-associated infections (HAIs), causing adverse consequences for patients including, but not limited to, increased length of hospital stay, healthcare costs, and mortality. Since the early 2000s, there has been a notable increase in CDI. Antimicrobial stewardship programs (ASPs) have responded to this public health threat with a number of different strategies including antimicrobial use reduction, education, appropriate testing, and multiple other interventions. Along with providing a literature review on ASP interventions to address the CDI threat, we describe our experience in successfully reducing HO-CDI at Northwestern Memorial Hospital with the use of multiple interventions.

Strategic Approach of an Urban 900-Bed Academic Medical Center to Combat Clostridium difficile Infection Transmission Using Staff Engagement

BACKGROUND: Preventing hospital-associated Clostridium difficile infection (HA-CDI) is crucial to modern healthcare systems for reducing mortality, healthcare costs and length of stay. As of 2011, Clostridium difficile infection (CDI) caused nearly 500,000 illnesses with 29,000 deaths in the United States. There are multiple risk factors for CDI; failure to comply with hand hygiene, ineffective equipment and surface cleaning as well as diagnosis delays can increase disease transmission. The objective is to promptly engage staff in discussion after HA-CDI to identify gaps and reduce infection rates in our facility.

Burden of Clostridium difficile Infections in Québec by Levy et al.

To the Editor—We read with great interest the article on the incidence and cost of Clostridium difficile infections (CDIs) in Canada by Levy et al [1]. This study provides valuable information, because little data exist on the burden associated with CDI in Canada. However, we would like to draw attention to the fact that the number of cases that occur every year in the province of Quebec has been overestimated more than 2-fold. In their study, Levy et al [1] estimated that 16 562 CDI cases occur in Quebec every year. This number is extrapolated from data of the Canadian Nosocomial Infection Surveillance Program (CNISP) [2]. Much more comprehensive data exist regarding CDI in Quebec that could have been used to draw a more accurate picture of the situation. Our province has implemented a mandatory CDI surveillance program in 2004 in the wake of the NAP1 epidemic [3]. Ninety-five acute-care institutions representing 99% of all patient admissions have the obligation to participate in this surveillance program conducted by the Institut National de Sante Publique du Quebec. Results are published in yearly reports and are publicly available [4]. Hospitals are subjected to government-imposed targets that are risk stratified according to hospital size, patient population, and academic mission [5]. Based on these official surveillance data, approximately 3700 primary hospital-associated CDI cases occurred every year in Quebec between 2010 and 2013, for a global incidence of approximately 7.0 per 10 000 patient-days. Using the authors' assumptions and calculation methods to estimate the number of community-acquired cases and the number of recurrences (which are not part of our surveillance program), approximately 7400 CDI cases occurs in this province each year, less than half the number of cases estimated by the authors and less than the province of Ontario. Their overestimation is probably due to sampling bias. Only 8 institutions in Quebec participate in the CNISP surveillance program, the source of data used by the authors to estimate the CDI burden in the province. Most of these hospitals are large academic institutions with intrinsically high CDI incidence. Inferring provincial data from these few hospitals has led to a sizeable overestimation of the true burden of CDI in the province. The impact of this overestimation on the conclusions of the study should be carefully addressed.

Hospital Clostridium difficile infection (CDI) incidence as a risk factor for hospital-associated CDI

Environmental risk factors for Clostridium difficile infections (CDIs) have been described at the room or unit level but not the hospital level. To understand the environmental risk factors for CDI, we investigated the association between institutional- and individual-level CDI. We performed a retrospective cohort study using the Healthcare Cost and Utilization Project state inpatient databases for California (2005-2011). For each patient's hospital stay, we calculated the hospital CDI incidence rate corresponding to the patient's quarter of discharge, while excluding each patient's own CDI status. Adjusting for patient and hospital characteristics, we ran a pooled logistic regression to determine individual CDI risk attributable to the hospital's CDI rate. There were 10,329,988 patients (26,086 cases and 10,303,902 noncases) who were analyzed. We found that a percentage point increase in the CDI incidence rate a patient encountered increased the odds of CDI by a factor of 1.182. As a point of comparison, a 1-percentage point increase in the CDI incidence rate that the patient encountered had roughly the same impact on their odds of acquiring CDI as a 55.8-day increase in their length of stay or a 60-year increase in age. Patients treated in hospitals with a higher CDI rate are more likely to acquire CDI.

Clostridium difficile infection incidence prediction in hospitals (CDIIPH): a predictive model based on decision tree and fuzzy techniques

Several risk factors associated with the increased likelihood of healthcare-associated Clostridium difficile infection (CDI) have been identified in the literature. These risk factors are mainly related to age, previous CDI, antimicrobial exposure, and prior hospitalization. No model is available in the published literature that can be used to predict the CDI incidence using healthcare administration data. However, the administrative data can be imprecise and may challenge the building of classical statistical models. Fuzzy set theory can deal with the imprecision inherent in such data. This research aimed to develop a model based on deterministic and fuzzy mathematical techniques for the prediction of hospital-associated CDI by using the explanatory variables controllable by hospitals and health authority administration. Retrospective data on CDI incidence and other administrative data obtained from 22 hospitals within a regional health authority in British Columbia were used to develop a decision tree (deterministic technique based) and a fuzzy synthetic evaluation model (fuzzy technique based). The decision tree model had a higher prediction accuracy than that of the fuzzy based model. However, among the common results predicted by two models, 72 % were correct. Therefore, this relationship was used to combine their results to increase the precision and the strength of evidence of the prediction. These models were further used to develop an Excel-based tool called C. difficile Infection Incidence Prediction in Hospitals (CDIIPH). The tool can be utilized by health authorities and hospitals to predict the magnitude of CDI incidence in the following quarter.

Hospital Incidence of Clostridium difficile Infection (CDI) as a Risk Factor for Hospital-Associated CDI

Hospital Incidence of Clostridium difficile Infection (CDI) as a Risk Factor for Hospital-Associated CDI

Incidence and Costs of Clostridium difficile Infections in Canada.

Background. Limited data are available on direct medical costs and lost productivity due to Clostridium difficile infection (CDI) in Canada. Methods. We developed an economic model to estimate the costs of managing hospitalized and community-dwelling patients with CDI in Canada. The number of episodes was projected based on publicly available national rates of hospital-associated CDI and the estimate that 64% of all CDI is hospital-associated. Clostridium difficile infection recurrences were classified as relapses or reinfections. Resource utilization data came from published literature, clinician interviews, and Canadian CDI surveillance programs, and this included the following: hospital length of stay, contact with healthcare providers, pharmacotherapy, laboratory testing, and in-hospital procedures. Lost productivity was considered for those under 65 years of age, and the economic impact was quantified using publicly available labor statistics. Unit costs were obtained from published sources and presented in 2012 Canadian dollars. Results. There were an estimated 37 900 CDI episodes in Canada in 2012; 7980 (21%) of these were relapses, out of a total of 10 900 (27%) episodes of recurrence. The total cost to society of CDI was estimated at $281 million; 92% ($260 million) was in-hospital costs, 4% ($12 million) was direct medical costs in the community, and 4% ($10 million) was due to lost productivity. Management of CDI relapses alone accounted for $65.1 million (23%). Conclusions. The largest proportion of costs due to CDI in Canada arise from extra days of hospitalization. Interventions reducing the severity of infection and/or relapses leading to rehospitalizations are likely to have the largest absolute effect on direct medical costs.

Substantial variation in hospital rankings after adjusting for hospital-level predictors of publicly-reported hospital-associated Clostridium difficile infection rates.

Across 366 California hospitals, we identified hospital-level characteristics predicting increased hospital-associated Clostridium difficile infection (HA-CDI) rates including more licensed beds, teaching and long-term acute care (LTAC) hospitals, and polymerase chain reaction testing. Adjustment for these characteristics impacted rankings in 24% of teaching hospitals, 13% of community hospitals, and 11% of LTAC hospitals.

Clostridium difficile infection after cardiac surgery: Prevalence, morbidity, mortality, and resource utilization

Despite increasing efforts to prevent infection, the prevalence of hospital-associated Clostridium difficile infections (CDI) is increasing. Heightened awareness prompted this study of the prevalence and morbidity associated with CDI after cardiac surgery. A total of 22,952 patients underwent cardiac surgery at Cleveland Clinic from January 2005 to January 2011. CDI was diagnosed by enzyme immunoassay for toxins and, more recently, polymerase chain reaction (PCR) testing. Hospital outcomes and long-term survival were compared with those of the remaining population in propensity-matched groups. One hundred forty-five patients (0.63%) tested positive for CDI at a median of 9 days postoperatively, 135 by enzyme immunoassay and 11 by PCR. Its prevalence more than doubled over the study period. Seventy-seven patients (48%) were transfers from outside hospitals. Seventy-three patients (50%) were exposed preoperatively to antibiotics and 79 (56%) to proton-pump inhibitors. Patients with CDI had more baseline comorbidities, more reoperations, and received more blood products than patients who did not have CDI. Presenting symptoms included diarrhea (107; 75%), distended abdomen (48; 34%), and abdominal pain (27; 19%). All were treated with metronidazole or vancomycin. Sixteen patients (11%) died in hospital, including 5 of 10 who developed toxic colitis; 3 of 4 undergoing total colectomy survived. Among matched patients, those with CDI had more septicemia (P < .0001), renal failure (P = .0002), reoperations (P < .0001), prolonged postoperative ventilation (P < .0001), longer hospital stay (P < .0001), and lower 3-year survival, 52% versus 64% (P = .03), than patients who did not have CDI. Although rare, the prevalence of CDI is increasing, contributing importantly to morbidity and mortality after cardiac surgery. If toxic colitis develops, mortality is high, but colectomy may be lifesaving.

Distinguishing Community-Associated From Hospital-Associated Clostridium difficile Infections in Children: Implications for Public Health Surveillance

Children are increasingly recognized as being at risk for C. difficile infection (CDI), even without prior exposure to antibiotics or the healthcare environment. We aimed to distinguish risk factors, clinical course, and outcomes between healthcare facility-associated (HA) and community-associated (CA) CDI. This was a retrospective, observational cohort study conducted at the Johns Hopkins Children's Center, Baltimore, Maryland. All inpatients, aged ≥1 year, hospitalized from July 2003 to July 2012 and diagnosed with CDI based on clinical characteristics and confirmatory laboratory testing were included. The main outcome was CDI, categorized as HA-CDI, CA-CDI, and "indeterminate" (classified as disease onset in the community, 4-12 weeks from hospital discharge). Two hundred two pediatric inpatients were diagnosed with CDI, of whom 38 had CA-CDI, 144 had HA-CDI, and 20 had indeterminate CDI. Children with indeterminate CDI had baseline characteristics similar to those identified for HA-CDI. Children hospitalized with CA-CDI were less likely to have comorbidities (odds ratio [OR], 0.14; 95% confidence interval [CI], .03-.65; P = .013), to have been exposed to antibiotics (OR, 0.17; 95% CI, .07-.44; P < .001), or prior surgeries (OR, 0.03; 95% CI, .00-.24; P = .001), compared to children with HA-CDI. Compared with HA-CDI, children with CA-CDI had a trend toward more episodes of septic shock (P = .07), toxic megacolon (P = .04), and recurrences (P = .04). In a hospitalized cohort, CA-CDI is more often seen in previously healthy children without antibiotic exposure or comorbid conditions and has more frequent complications and recurrences compared to HA-CDI. For surveillance purposes, "indeterminate" CDI should be allocated to HA-CDI rather than CA-CDI.

Inappropriate use of antibiotics and Clostridium difficile infection

We assessed appropriateness of preceding and concurrent antibiotics in 126 consecutive patients with hospital-associated Clostridium difficile infection. In 93 (73.8%) episodes, at least 1 preceding course of antibiotics was inappropriate. We provided feedback on concurrent antibiotics on the day of diagnosis during the final 8 months: 17 of 74 (23.0%) patients were on inappropriate antibiotics. Our recommendations were well received. Reviewing C difficile-infected patients allowed for identification of opportunities to improve antibiotic utilization and potentially improved patient outcomes.

The effect of portable pulsed xenon ultraviolet light after terminal cleaning on hospital-associated Clostridium difficile infection in a community hospital

There is evidence that contamination of patient rooms from previous occupants is associated with hospital-associated Clostridium difficile infection (HA-CDI). During January 2011, the use of 2 portable pulsed xenon ultraviolet light devices (PPX-UV) to disinfect patient rooms was added to routine hospital discharge cleaning in a community hospital. In 2010, the HA-CDI rate was 9.46 per 10,000 patient-days; in2011, the HA-CDI rates was 4.45 per 10,000 patient-days (53% reduction, P= .01). The number of deaths and colectomies attributable to hospital-associated C difficile infection also declined dramatically.

Validation of the chronic disease score-infectious disease (CDS-ID) for the prediction of hospital-associated clostridium difficile infection (CDI) within a retrospective cohort

BackgroundAggregate comorbidity scores are useful for summarizing risk and confounder control in studies of hospital-associated infections. The Chronic Disease Score – Infectious Diseases (CDS-ID) was developed for this purpose, but it has not been validated for use in studies of Clostridium difficile Infection (CDI). The aim of this study was to assess the discrimination, calibration and potential for confounder control of CDS-ID compared to age alone or individual comorbid conditions.MethodsSecondary analysis of a retrospective cohort study of adult inpatients with 2 or more days of antibiotic exposure at a tertiary care facility during 2005. Logistic regression models were used to predict the development of CDI up to 60 days post-discharge. Model discrimination and calibration were assessed using the c-statistic and Hosmer-Lemeshow (HL) tests, respectively. C-statistics were compared using chi-square tests.ResultsCDI developed in 185 out of 7,792 patients. The CDS-ID was a better standalone predictor of CDI than age (c-statistic 0.653 vs 0.609, P=0.04). The best discrimination was observed when CDS-ID and age were both used to predict CDI (c-statistic 0.680). All models had acceptable calibration (P>0.05).ConclusionThe CDS-ID is a valid tool for summarizing risk of CDI associated with comorbid conditions.

Clostridium difficileinfection in the community: Are proton pump inhibitors to blame?

Once a nosocomial disease, Clostridium difficile infection (CDI) now appears frequently in the community in the absence of exposure to antibiotics. Prior studies have shown that patients with community-acquired CDI are younger, more likely to be female, and have fewer comorbidities compared to patients with hospital-associated CDI. Because most studies of CDI are hospital-based, comparatively little is known about community-acquired CDI. The recent study by Chitnis has received widespread attention because it used active surveillance to capture all cases of community-acquired CDI within a large population and assessed key risk factors. The authors found that low-level healthcare exposure and proton pump inhibitor use were common among those with non-antibiotics associated, community-acquired CDI. In this commentary, we discuss the changing epidemiology of community-acquired CDI and the evidence basis for the controversial association between proton pump inhibitors and community-acquired CDI.

Surveillance for Clostridium Difficile Infection in Nursing Homes

To define the time of onset of Clostridium difficile infection (CDI) in the community nursing home setting. Retrospective. Four community nursing homes. Residents with incident CDI identified from infection control surveillance records. Cases were divided into two groups depending on the time of onset of infection: within 30 days of admission after hospitalization or more than 30 days after admission to a nursing home after hospitalization. Of 75 incident CDI cases, 52 (69%) developed within 30 days of admission and 23 (31%) more than 30 days after admission. Of the 52 cases that developed within 30 days, 68% were in residents admitted for subacute care. The mean number of days ± standard deviation to CDI was 10.5 ± 2.5 in those who developed infection within 30 days; 75% of these cases developed within 15 days of admission. The majority of CDI in the study nursing homes developed within 30 days of admission; this group may be analogous to community-onset, hospital-associated CDI as defined in the Centers for Disease Control and Prevention (CDC) surveillance definitions. Therefore, the proposed CDC surveillance definitions may overestimate the incidence of nursing home-associated CDI.

Characterization of Cases of Clostridium difficile Infection (CDI) Presenting at an Emergency Room: Molecular and Clinical Features Differentiate Community-Onset Hospital-Associated and Community-Associated CDI in a Tertiary Care Hospital

Definition of community-onset, hospital-acquired Clostridium difficile infection (CO-HA-CDI) is difficult in patients presenting with diarrhea at hospitals or outpatient clinics, especially 4 to 12 weeks after the last discharge. We performed C. difficile stool culture for 272 diarrheic patients visiting the emergency room (ER) between January 2006 and June 2010. C. difficile was isolated from 36 cases (13.2%), and isolation rates increased year by year, from 10.1% in 2008 to 12.4% in 2009 and 16.7% in 2010. Among 32 toxin-positive isolates, 13 (40.6%) and 19 (59.4%) were associated with CO-HA-CDI and community-acquired CDI (CA-CDI), respectively, if cases with CDI diagnosed within 12 weeks after discharge were considered hospital associated. The majority (70%) of CO-HA-CDI cases occurred within 2 weeks after hospital discharge, although the interval from discharge to onset of symptoms was as long as 10 weeks. We found via tcdA and tcdB and repetitive sequence PCR analysis, that toxin A-positive/toxin B-positive isolates were the most prevalent in both CO-HA-CDI (53.8%) and CA-CDI (94.7%) cases. Toxin A-negative/toxin B-positive isolates were also still highly associated with HA-CDI cases but were also observed in CA-CDI cases. Younger age, fewer underlying diseases, lack of prior antibiotic use, and genetic diversity of isolates in repetitive sequence PCR were the main characteristics in CA-CDI cases visiting the ER.