Picture of C. difficile Infection Changing in the US

By Megan Brooks

July 30, 2014

NEW YORK (Reuters Health) - The current epidemic of Clostridium difficile infection (CDI) in the United States may be shifting from hospitals to community settings.

In a study, researchers with Kaiser Permanente Southern California in Pasadena found that the majority of hospitalized patients who tested positive for C. difficile did so outside the hospital or within the first 72 hours of hospitalization.

This suggests that community settings may be important for identification and potential transmission of the disease, they note in a report online July 22 in Mayo Clinic Proceedings.

CDI is a "major public health concern in the US, with infection rates tripling over the last decade," lead author Dr. Sara Y. Tartof notes in a Kaiser news release.

Traditionally, CDI has been associated with hospitals and other inpatient healthcare settings, affecting mainly older adults with multiple comorbid conditions.

"However, emerging data suggest a possible increased role of community-based onset and transmission, which can include relatively healthy populations," the researchers write in their article.

They reviewed the electronic health records of patients in Southern California who were admitted to 14 Kaiser Permanente hospitals in 2011 and 2012.

"Kaiser Permanente's integrated health care system allowed us to track patients after they left the hospital in both the outpatient health setting and during a readmission which contributed an important new perspective to the current C. diff story," Dr. Tartof explains in the release.

"Previous studies typically focused on diagnoses during a hospital stay, which tells only part of the story. These findings emphasize how important it is to test for the infection both in the hospital as well as in outpatient settings," she adds.

Among a total of 268,655 patients, 4286 (1.6%) had at least one positive laboratory test for CDI. Forty-nine percent of these infections were acquired in the community or from an indeterminate source and 31% were associated with a previous hospitalization, the researchers say.

"People may be leaving the hospital with infection and showing up in an outpatient clinic. I think outpatient clinics may not think of C. diff right away because C. diff has a reputation for being a hospital problem seen in older inpatients," Dr. Tartof noted in an interview with Reuters Health.

Among CDI patients, 671 (15.7%) had recurrent infections. The incidence rate was highest among community-onset, health care facility-associated infections (11.1 per 10,000 inpatient-days).

"As the CDI epidemic evolves, ongoing assessments of CDI incidence, transmission patterns, and effect on health care settings are imperative," the researchers note in their article.

"Our data provide supporting evidence of a changing CDI epidemic. Health care contact remains a critical focal point of acquiring CDI; however, we found a substantial role for community-based identification, onset, and possibly transmission," they write.

"Our cohort included only patients with inpatient exposure, yet 80% of positive C. difficile test results were collected in the outpatient setting or within the first 72 hours of a hospitalization," they point out.

CDI was most common in non-Hispanic whites (44.1%) and women (62.6%) and rates rose with age. Several comorbidities were also associated with CDI including dementia, connective tissue disease, rheumatic disease, and peripheral vascular disease.

"This paper does not look at risk," Dr. Tartof said, but it "sets the stage" for a forthcoming paper that does look at risk factors.

Overall, 528 patients (12.3%) died within a month of a positive CDI test result.

An analysis comparing pre- and post-polymerase chain reaction (PCR) testing periods showed a 34% increase in CDI incidence rates after implementation of PCR testing. "The PCR-based tests have increased sensitivity and are increasingly replacing enzyme immunoassay (EIA) for CDI in clinical laboratories," the researchers say.

According to the Centers for Disease Control and Prevention, over the past several years, states have noted higher rates of CDI and related deaths.

"Kaiser Permanente works diligently to prevent C. diff infections in both the hospital and ambulatory settings," Dr. Michael Kanter, regional medical director of quality and clinical analysis, Southern California Permanente Medical Group, comments in the news release.

"We promote judicious use of antibiotics, we make painstaking efforts to ensure our staff and health care providers practice hand hygiene, we prompt testing of symptomatic patients, and we conduct vigorous cleaning of rooms with special cleaning agents known to kill C. diff when patients with the infection are identified," he explains.

SOURCE: http://bit.ly/1Att9Wv

Mayo Clin Proc 2014.

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