Most C diff Healthcare-Related, but Not From Hospital Care

Emma Hitt, PhD

March 06, 2012

March 6, 2012 — Among healthcare-associated Clostridium difficile infections (CDIs), 75% have their onset outside of hospitals, and 52% of the CDIs treated in hospitals are already present upon admission, according to a new report from the US Centers for Disease Control and Prevention (CDC).

The findings were presented today in an early-release version of the CDC's March 6 issue of the Morbidity and Mortality Weekly Report.

According to the CDC, the estimated number of deaths attributed to CDIs has increased more than 400%, from 3000 deaths per year during 1999-2000 to 14,000 deaths per year during 2006-2007, with more than 90% of deaths in persons aged 65 years or older.

"Although the incidence of other health-care–associated infections has declined, CDIs have increased and only recently plateaued," note the researchers, led by L. Clifford McDonald, MD, a medical epidemiologist with the Division of Healthcare Quality Promotion at the CDC's National Center for Emerging and Zoonotic Infectious Diseases.

The researchers also note that the "ability of programs to prevent CDIs by implementing CDC recommendations across a range of hospitals" has not previously been demonstrated.

In the current study, the CDC analyzed population-based data from the Emerging Infections Program, as well as CDIs reported to the National Healthcare Safety Network (NHSN).

They found that in the Emerging Infections Program in 2010, 94% of CDIs were linked to receipt of healthcare. However, of those infections, 75% developed in nonhospitalized patients, including those who were recently discharged from the hospital, outpatients, and nursing home residents.

Among CDIs reported to the NHSN in 2010, 52% were already present on hospital admission, and according to the CDC, represent "a potential source for intrahospital transmission." Most were related to previous healthcare, however.

The researchers also compared the rates of hospital-onset CDIs between two 8-month periods at the start and completion of 3 programs primarily designed to prevent intrahospital transmission of CDIs in 3 states: Illinois, Massachusetts, and New York.

The CDI prevention programs, which took place in 71 hospitals in the 3 states, were associated with a 20% decrease in CDI rate during the periods measured.

Study weaknesses include, but are not limited to, lack of data about antibiotic exposure and about implementation of CDI prevention strategies.

"Because nearly 75% of all CDIs related to U.S. health care have their onset outside of hospitals, more needs to be done to prevent CDIs across all health-care settings," Dr. McDonald and colleagues conclude.

They suggest that prevention approaches include "a greater focus on antibiotic stewardship and extending prevention strategies in settings across the continuum of health-care delivery."

In a media briefing held by the CDC today, Dr. McDonald described 6 steps recommended by the CDC to prevent infection. "First, prescribe and use antibiotics carefully.... Second, test for C difficile when patients have diarrhea while on antibiotics or within several months after taking them. Third, isolate patients with C difficile immediately. Fourth, wear gloves and gowns when treating patients with C difficile, even during short visits…. Fifth, clean room surfaces with bleach or another [Environmental Protection Agency]-approved spore-killing disinfectant after a patient with C difficile has been treated there. And finally, when patients transfer, notify the new facility of C difficile infections."

Dr. McDonald emphasized "the need for strict adherence to infection prevention and control recommendations across all facility types, and the need for greater care coordination" and pointed out that "when CDC recommendations are followed well...C difficile can be prevented."

The authors have disclosed no relevant financial relationships.

Morb Mortal Wkly Rep. 2012;61;1-6. Full text

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