Preventing Clostridium difficile Infections

In This Article

Abstract and Introduction

Abstract

Background: Clostridium difficile infection (CDI) is a common and sometimes fatal health-care–associated infection; the incidence, deaths, and excess health-care costs resulting from CDIs in hospitalized patients are all at historic highs. Meanwhile, the contribution of nonhospital health-care exposures to the overall burden of CDI, and the ability of programs to prevent CDIs by implementing CDC recommendations across a range of hospitals, have not been demonstrated previously.
Methods: Population-based data from the Emerging Infections Program were analyzed by location and antecedent health-care exposures. Present-on-admission and hospital-onset, laboratory-identified CDIs reported to the National Healthcare Safety Network (NHSN) were analyzed. Rates of hospital-onset CDIs were compared between two 8-month periods near the beginning and end of three CDI prevention programs that focused primarily on measures to prevent intrahospital transmission of C. difficile in three states (Illinois, Massachusetts, and New York).
Results: Among CDIs identified in Emerging Infections Program data in 2010, 94% were associated with receiving health care; of these, 75% had onset among persons not currently hospitalized, including recently discharged patients, outpatients, and nursing home residents. Among CDIs reported to NHSN in 2010, 52% were already present on hospital admission, although they were largely health-care related. The pooled CDI rate declined 20% among 71 hospitals participating in the CDI prevention programs.
Conclusions: Nearly all CDIs are related to various health-care settings where predisposing antibiotics are prescribed and C. difficile transmission occurs. Hospital-onset CDIs were prevented through an emphasis on infection control.
Implications for Public Health: More needs to be done to prevent CDIs; major reductions will require antibiotic stewardship along with infection control applied to nursing homes and ambulatory-care settings as well as hospitals. State health departments and partner organizations have shown leadership in preventing CDIs in hospitals and can prevent more CDIs by extending their programs to cover other health-care settings.

Introduction

Clostridium difficile is an anaerobic, spore-forming bacillus that causes pseudomembranous colitis, manifesting as diarrhea that often recurs and can progress to toxic megacolon, sepsis, and death. Infection is spread by the fecal-oral route; spores, the infective form, can persist on fomites and environmental surfaces for months. Clostridium difficile infection (CDI) often occurs in patients in health-care settings, where antibiotics are prescribed and symptomatic patients, an important source for transmission, are concentrated. From 2000 to 2009, the number of hospitalized patients with any CDI discharge diagnoses more than doubled, from approximately 139,000 to 336,600, and the number with a primary CDI diagnosis more than tripled, from 33,000 to 111,000.^[1] Although the incidence of other health-care–associated infections has declined,^[2] CDIs have increased and only recently plateaued.^[1] Evidence-based guidelines for the prevention of CDIs in hospitals have been published.^[3] However, because the evidence for many of these recommendations is weak^[4] the degree to which they can prevent CDIs effectively across a range of hospitals is unknown, as is the relative burden of CDIs in nonhospital and hospital health-care settings.

Table 1. Number and percentage of hospitals reporting laboratory-identified *Clostridium difficile* infections, by selected characteristics — United States, National Healthcare Safety Network, 2010
Characteristic	No.	(%)
Total	711	(100)
Bed size
≤200	429	(61)
201–500	232	(33)
501–1000	46	(6)
>1000	1	(<0.5)
Medical school affiliation	226	(31)
Primary diagnostic assay used
Enzyme immunoassay for toxin A and/or B	364	(51)
Nucleic acid amplification test	238	(33)
Other	88	(12)
Missing data	21	(3)

Table 2. Reductions in hospital-onset *Clostridium difficile* infection rates — Illinois, Massachusetts, and New York, May 2008–October 2011*
State	Period	Patient days	Rate	(95% CI*)	Rate ratio	(95% CI)
Illinois	Mar 2010–Oct 2010	637,135	11.6	(10.3–13.0)	0.84	(0.70–1.00)
Illinois	Mar 2011–Oct 2011	578,121	9.9	(8.4–11.4)
Massachusetts	Feb 2010–Sep 2010	823,939	7.6	(6.7–8.5)	0.75	(0.63–0.90)
Massachusetts	Feb 2011–Sep 2011	830,023	5.7	(4.9–6.5)
New York	May 2008–Dec 2008	2,607,464	9.2	(8.5–9.9)	0.81	(0.73–0.89)
New York	May 2009–Dec 2009	2,575,514	7.5	(7.0–8.0)
Overall	Pooled baseline	4,068,538	9.3	(8.7–9.8)	0.80	(0.73–0.86)
Overall	Pooled post	3,983,658	7.5	(7.0–7.9)

Abbreviation: CI = confidence interval.
* Study periods vary by state.

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