Vital Signs: Preventing Clostridium difficile Infections

L. Clifford McDonald, MD; Fernanda Lessa, MD; Dawn Sievert, PhD; Matt Wise, PhD; Rosa Herrera; Carolyn Gould, MD; Paul Malpiedi, MPH; Maggie Dudeck, MPH; Arjun Srinivasan, MD; Scott Fridkin, MD; Denise Cardo, MD


Morbidity and Mortality Weekly Report. 2012;61(9):157-162. 

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In this investigation, three data sources were used to identify health-care exposures for CDIs, determine the proportion of CDIs occurring outside hospital settings, and assess whether prevention programs can effectively reduce CDIs. CDC's Emerging Infections Program conducted active, population-based surveillance for CDIs from eight diverse geographic areas in 2010.[5] Program surveillance coordinators received laboratory reports of positive stool C. difficile tests from residents of catchment areas. Cases were defined by a positive C. difficile test in a person without a positive test during the previous 8 weeks (repeat positive tests during this period suggest recurrence).[6] Medical records were reviewed to confirm the presence of symptoms consistent with CDI and to record all health-care exposures during the 12 weeks preceding specimen collection (i.e., minimum duration of antibiotic-induced susceptibility to CDI). CDIs were classified by the patient's location at the time of stool specimen collection and divided into three groups: 1) hospital-onset CDI, occurring in a hospitalized patient with a positive stool specimen collected more than 3 days after admission; 2) nursing home–onset CDI, occurring in a nursing home resident with a positive stool specimen collected at any time during their stay; and 3) community-onset CDI, occurring in an outpatient or an inpatient of any health-care facility with a positive stool specimen collected within 3 days (the median incubation period of C. difficile) after admission. Community-onset CDI cases were subcategorized based on previous health-care exposures during the 12 weeks preceding specimen collection; previous inpatient exposures took precedence over outpatient exposures when classifying cases.

A second data source was the National Healthcare Safety Network (NHSN) Multidrug-Resistant Organism and Clostridium difficile Infection module for laboratory-identified (LabID)-CDI events, which became available in March 2009.[7] Incident LabID-CDI events in NHSN are based on positive C. difficile test results from hospital patients who did not have a previous positive test result reported within that facility during the preceding 8 weeks. LabID-CDI events present on admission were defined by a positive stool specimen collected within the first 3 days of admission; a subset was delineated further if patients were discharged from the reporting hospital in the preceding 4 weeks, during which time previous hospitalization is most likely to influence the risk for CDI.[6,7] Rates of hospital-onset CDI cases were calculated per 10,000 patient-days.

The third set of data included early results from three state-led programs (Illinois, Massachusetts, and New York) similar to other programs in which hospitals collaborated with one another to prevent health-care–associated infections[8] (in this case, hospital-onset CDIs). The three programs included a total of 71 hospitals focused on preventing CDIs during three different periods ranging from 19 to 22 months.* Although the systems for data collection and behavioral change strategies varied among programs, all three used CDC surveillance definitions[6] and focused primarily on infection control interventions to prevent transmission of C. difficile; the Massachusetts program did include antibiotic stewardship as a minor component. Using a negative binomial model, rates of hospital-onset CDI from hospitals participating in the three programs were compared between two same-calendar-month, 8-month periods (to control for seasonal variation in rates), one earlier and the other later in the conduct of each program.

* The Illinois prevention program, led by the Department of Public Health and the Iowa Foundation for Medical Care–Illinois (a health-care quality improvement organization headquartered in West Des Moines, Iowa), included 11 hospitals with complete data from the beginning of March 2010 through October 2011. The Massachusetts program, led by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Department of Public Health, included 27 hospitals with complete data from January 2010 through September 2011. The New York program, led by the Greater New York Hospital Association and the United Hospital Fund in collaboration with the New York State Department of Health, included 33 hospitals with complete data from March 2008 through December 2009.


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