Identifying Targets for Prevention Through Clostridium difficile Population Surveillance
Antibiotics and Clostridium difficile spores exposures are both important factors for the development of C. difficile infection (CDI). Patient movements across healthcare facilities help with C. difficile spread. Designing CDI prevention strategies requires an understanding of these transmission dynamics as well as predisposing factors.
Population-based surveillance for CDI started in 2010 in Monroe County, NY as part of the CDC’s Emerging Infections Program. Medical chart reviews were performed on all county residents with positive C. difficile tests reported by the laboratories. Incident CDI cases had no history of a C. difficile positive test in the prior 8 weeks. We divided CDI cases into 4 epidemiologic classifications depending on location of patient at the time of testing: community-associated (CA: no overnight stay at hospital or long-term facility (LTCF) in the previous 12 weeks), community onset healthcare facility-associated (COHCFA: positive test within 12 weeks of discharge from healthcare), hospital onset (HO) and long-term care facility onset (LTCFO).
Over 4 years, 6642 incident CDI cases were identified across the county which includes 4 hospitals and 33 LTCFs, for an average annual incidence of 225 per 100,000 population. Thirty-five percent of CDI cases were CA, 20% COHCFA, 23% HO and 22% LTCFO. Exposure to the hospital prior to CDI was common, as 55% COHCFA and 47% LTCFO cases were discharged from the hospital in the 30 days prior to CDI. In addition, hospitalization within 7 days of CDI occurred in 29% of CA cases. Twenty-eight percent of LTCFO and 58% of COHCFA cases were re-hospitalized. Forty percent of HO cases were discharged to LTCF. The majority of CDI cases received antibiotics 12 weeks prior to their illness; 89% of COHCFA, 97% of HO, 86% of LTCO and 60% of CA CDI cases.
CDI patients frequently moved across the continuum of care and the community, facilitating C. difficile spread. Antibiotic use prior to infection was common. Reducing the local burden of CDI therefore requires a community-wide approach harmonizing both infection control and antimicrobial stewardship efforts in the hospital, LTCF and outpatient settings.
D. Nelson, None
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