Outpatient Healthcare Settings and Transmission of Clostridium difficile (original) (raw)
PLoS ONE, 2014
Background: Recent evidence suggests that less than one-quarter of patients with symptomatic nosocomial Clostridium difficile infections (CDI) are linked to other in-patients. However, this evidence was limited to one geographic area. We aimed to investigate the level of symptomatic CDI transmission in hospitals located across England from 2008 to 2012. Methods: A generalized additive mixed-effects Poisson model was fitted to English hospital-surveillance data. After adjusting for seasonal fluctuations and between-hospital variation in reported CDI over time, possible clustering (transmission between symptomatic in-patients) of CDI cases was identified. We hypothesised that a temporal proximity would be reflected in the degree of correlation between in-hospital CDI cases per week. This correlation was modelled through a latent autoregressive structure of order 1 (AR(1)). Findings: Forty-six hospitals (33 general, seven specialist, and six teaching hospitals) located in all English regions met our criteria. In total, 12,717 CDI cases were identified; seventy-five per cent of these occurred .48 hours after admission. There were slight increases in reports during winter months. We found a low, but statistically significant, correlation between successive weekly CDI case incidences (phi = 0.029, 95%CI: 0.009-0.049). This correlation was five times stronger in a subgroup analysis restricted to teaching hospitals (phi = 0.104, 95%CI: 0.048-0.159). Conclusions: The results suggest that symptomatic patient-to-patient transmission has been a source of CDI-acquisition in English hospitals in recent years, and that this might be a more important transmission route in teaching hospitals. Nonetheless, the weak correlation indicates that, in line with recent evidence, symptomatic cases might not be the primary source of nosocomial CDI in England.
Multicenter Study of Clostridium difficile Infection Rates from 2000 to 2006
Infection Control and Hospital Epidemiology, 2010
Objective-To compare Clostridium difficile infection (CDI) incidence rates during a 6-year period among five geographically diverse academic medical centers across the United States using recommended standardized CDI surveillance definitions that incorporate recent healthcare facility (HCF) exposures. Methods-Data on C. difficile toxin assay results and dates of admission, discharge and assays were collected from electronic hospital databases. Chart review was performed for patients with a positive C. difficile toxin assay identified within 48 hrs of admission to determine HCF exposures in the 90 days prior to hospital admission. CDI cases, defined as any inpatient with a positive stool toxin assay for C. difficile, were categorized into five surveillance definitions based on recent HCF exposure. Annual CDI rates were calculated and evaluated with chi-square test for trend and chi-square summary tests. Results-Over the study period, there were significant increases in the overall incidence rates of hospital-onset, HCF-associated CDI (7.0 to 8.5 cases/10,000 patient days (p < 0.001)); community-onset, HCF-associated-study hospital CDI (1.1 to 1.3 cases/10,000 patient-days (p = 0.003)); and community-onset, HCF-associated-other HCF CDI (0.8 to 1.5 cases/1,000 admissions overall (p < 0.001)). For each CDI surveillance definition, there were significant differences in total incidence rates between institutions. Conclusions-The increasing incidence rates of CDI over time and across institutions, and correlation of CDI incidence in different categories suggest that CDI may be a regional problem, and not isolated to single healthcare facilities.
Contamination of a hospital environment byClostridium difficile
Current Microbiology, 1979
Clostridium difficile was recovered from a variety of environmental sites in three hospital rooms occupied by a patient who had colitis due to this organism. C difficile was detected for 40 days after the patient was moved from one of these rooms, These findings suggest that the contaminated hospital environment may be a clinically significant reservoir for C. difficite and that this organism may be a nosocomial pathogen. Isolation of patients and adequate decontamination of rooms may be needed to minimize risk to other patients.
BMC Infectious Diseases, 2016
Background: Clostridium difficile (CD) is a leading cause of diarrhoea among hospitalized patients. The objective of this study was to evaluate the rate, the optimal diagnostic work-up, and outcome of CD infections (CDI) in Internal Medicine (IM) wards in Italy. Methods: PRACTICE is an observational prospective study, involving 40 IM Units and evaluating all consecutive patients hospitalized during a 4-month period. CDI were defined in case of diarrhoea when both enzyme immunoassay for GDH, and test for A/B toxin were positive. Patients with CDI were followed-up for recurrences for 4 weeks after the end of therapy. Results: Among the 10,780 patients observed, 103 (0.96 %) showed CDI, at admission or during hospitalization. A positive history for CD, antibiotics in the previous 4 weeks, recent hospitalization, female gender and age were significantly associated with CDI (multivariable analysis). In-hospital mortality was 16.5 % in CD group vs 6.7 % in No-CD group (p < 0.001), whereas median length of hospital stay was 16 (IQR = 13) vs 8 (IQR = 8) days (p < 0.001) among patients with or without CDI, respectively. Rate of CD recurrences was 14.6 %. As a post-hoc evaluation, 23 out of 34 GDH+/Tox-samples were toxin positive, when analysed by molecular method (a real-time PCR assay). The overall CD incidence rate was 5.3/10,000 patient-days. Conclusions: Our results confirm the severity of CDI in medical wards, showing high in-hospital mortality, prolonged hospitalization and frequent short-term recurrences. Further, our survey supports a 2-3 step algorithm for CD diagnosis: EIA for detecting GDH, A and B toxin, followed by a molecular method in case of toxin-negative samples.
Epidemiology of Community-Associated Clostridium difficile Infection, 2009 Through 2011
JAMA Internal Medicine, 2013
IMPORTANCE Clostridium difficile infection (CDI) has been increasingly reported among healthy individuals in the community. Recent data suggest that community-associated CDI represents one-third of all C difficile cases. The epidemiology and potential sources of C difficile in the community are not fully understood. OBJECTIVES To determine epidemiological and clinical characteristics of communityassociated CDI and to explore potential sources of C difficile acquisition in the community. DESIGN AND SETTING Active population-based and laboratory-based CDI surveillance in 8 US states. PARTICIPANTS Medical records were reviewed and interviews performed to assess outpatient, household, and food exposures among patients with community-associated CDI (ie, toxin or molecular assay positive for C difficile and no overnight stay in a health care facility within 12 weeks). Molecular characterization of C difficile isolates was performed. Outpatient health care exposure in the prior 12 weeks among patients with communityassociated CDI was a priori categorized into the following 3 levels: no exposure, low-level exposure (ie, outpatient visit with physician or dentist), or high-level exposure (ie, surgery, dialysis, emergency or urgent care visit, inpatient care with no overnight stay, or health care personnel with direct patient care). MAIN OUTCOMES AND MEASURES Prevalence of outpatient health care exposure among patients with community-associated CDI and identification of potential sources of C difficile by level of outpatient health care exposure. RESULTS Of 984 patients with community-associated CDI, 353 (35.9%) did not receive antibiotics, 177 (18.0%) had no outpatient health care exposure, and 400 (40.7%) had low-level outpatient health care exposure. Thirty-one percent of patients without antibiotic exposure received proton pump inhibitors. Patients having CDI with no or low-level outpatient health care exposure were more likely to be exposed to infants younger than 1 year (P = .04) and to household members with active CDI (P = .05) compared with those having high-level outpatient health care exposure. No association between food exposure or animal exposure and level of outpatient health care exposure was observed. North American pulsed-field gel electrophoresis (NAP) 1 was the most common (21.7%) strain isolated; NAP7 and NAP8 were uncommon (6.7%). CONCLUSIONS AND RELEVANCE Most patients with community-associated CDI had recent outpatient health care exposure, and up to 36% would not be prevented by reduction of antibiotic use only. Our data support evaluation of additional strategies, including further examination of C difficile transmission in outpatient and household settings and reduction of proton pump inhibitor use.
Open Forum Infectious Diseases, 2022
Introduction Patients with Clostridioides difficile infections (CDI) contaminate the healthcare environment; however, the relative contribution of contamination by colonized individuals is unknown. Current guidelines do not recommend the use of contact precautions for asymptomatic C. difficile carriers. We evaluated C. difficile environmental contamination in rooms housing adult inpatients with diarrhea based on C. difficile status. Methods We performed a prospective cohort study of inpatient adults with diarrhea who underwent testing for CDI via PCR and enzyme immunoassay. Patients were stratified into cohorts based on test result: infected (PCR +/EIA +), colonized (PCR +/EIA -) or negative/control (PCR -). Environmental microbiological samples were taken within 24 hours of C. difficile testing and again for two successive days. Samples were obtained from the patient, bathroom, and care areas. Results We enrolled 94 patients between November 2019 and June 2021. C. difficile was rec...