C difficile Infected Almost Half a Million in Single Year

Troy Brown, RN

Disclosures

February 25, 2015

Clostridium difficile caused nearly half a million infections and was associated with about 29,000 deaths in 2011, according to new data released today by the Centers for Disease Control and Prevention (CDC).

"C. difficile is a bacteria that causes severe diarrhea and damage to the colon, and is often triggered by exposure to antibiotics. Infections with C. difficile have become increasingly common over the last few decades and are seen in patients in healthcare facilities as well as people in their communities," Michael Bell, MD, deputy director, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia, said in a CDC telebriefing.

"In the past, patients infected with C. difficile have had diarrhea related to antibiotic use that was often perceived as a nuisance, but not a major problem. Unfortunately, the type of C. difficile circulating in the US today produces such a powerful toxin that [it] can cause a truly deadly diarrhea," Dr Bell explained.

"Patients receiving antibiotics are now at risk for not just mild diarrhea, but intense illness that can cause damage to the bowel so painful and severe that part of the colon needs to be surgically removed, a condition called toxic megacolon."

Fernanda C. Lessa, MD, MPH, from the Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, and colleagues report their findings in an article published in the February 26 issue of the New England Journal of Medicine.

They performed active population- and laboratory-based surveillance across 10 geographic areas in the United States in 2011 to identify C difficile infection cases, which they defined as stool specimens positive for C difficile on either toxin or molecular assay in residents aged 1 year or older. They classified cases as community-associated or healthcare-associated. In a sample of cases, they cultured specimens and conducted molecular typing on isolates.

Using regression models, they calculated estimates of national incidence and the total number of infections, first recurrences, and deaths that occurred within 30 days after diagnosis. The investigators identified 15,461 cases of C difficile infection in the 10 geographic areas; 65.8% of these were healthcare-associated, but only 24.2% began during hospitalization.

The authors adjusted for predictors of disease incidence, including age, sex, race, and a rate of use of nucleic acid amplification test (NAAT) of 52% for community-associated cases, and age, inpatient days, and a rate of use of NAAT of 52% for healthcare-associated cases.

After adjustment, the estimated number of incident infections in the United States was 453,000 (95% confidence interval [CI], 397,100 - 508,500). The researchers estimated the incidence to be higher among females (rate ratio, 1.26; 95% CI, 1.25 - 1.27), whites (rate ratio, 1.72; 95% CI, 1.56 - 2.0), and persons 65 years of age or older (rate ratio, 8.65; 95% CI, 8.16 - 9.31).

According to the researchers' estimates, the number of first recurrences was 83,000 (95% CI, 57,000 - 108,900), and the number of deaths was 29,300 (95% CI, 16,500 - 42,100).

Healthcare-Associated Infection Worse

The estimated rate of first recurrence was 13.5% among those with community-associated infection and 20.9% among those with healthcare-associated infection.

The estimated rate of death within 30 days was 1.3% among those with community-associated infection and 9.3% among those with healthcare-associated infection.

The North American pulsed-field gel electrophoresis type 1 (NAP1) strain was more common among healthcare-associated infections than among community-associated infections (30.7% vs 18.8%; P < .001).

"In the absence of a vaccine, future efforts to prevent C. difficile will cross health care settings and focus more on appropriate antibiotic use, which has been shown to be successful in decreasing rates of C. difficile infection in England, where a multifaceted program including antimicrobial stewardship was implemented," the authors explain.

"The prevention of C. difficile infection is a U.S. priority, with 2020 national reduction targets being established and all hospitals participating in the Hospital Inpatient Quality Reporting Program of the Centers for Medicare and Medicaid Services, which has reported data regarding C. difficile infection to the National Healthcare Safety Network since 2013," they conclude.

Healthcare providers can prevent C difficile by taking the following steps:

  • Prescribe and use antibiotics carefully.

  • Test patients who have diarrhea while receiving antibiotics for C difficile while they are ill or within several months of taking antibiotics.

  • Immediately isolate patients with C difficile.

  • Wear gloves and gowns when caring for patients with C difficile. Hand sanitizer will not kill C difficile, and hand washing may be insufficient.

  • Clean room surfaces with bleach or another US Environmental Protection Agency–approved, spore-killing disinfectant after treating a patient with C difficile in that room.

  • When transferring a patient, notify the new facility if that patient is infected with C difficile.

The study was funded by the CDC. One author reports receiving personal fees from ViroPharma/Shire, Merck, Rebiotix, Actelion, Sanofi Pasteur, MedImmune, Summit, and Cubist outside the submitted work. In addition, that author reports a patent related to the treatment and prevention of CDI, which is licensed to ViroPharma/Shire. The remaining authors and Dr Bell have disclosed no relevant financial relationships.

N Engl J Med. 2015;372:825-834. Abstract

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