Volume 22, Number 4—April 2016
Quantifying Transmission of Clostridium difficile within and outside Healthcare Settings
|Parameter description||Prior rate (95% CI)†||Posterior rate (95% CI)†||Reference|
|All-cause CDI mortality rate, %||(28)|
|<50||4.7 (2.6–7.6)||4.5 (2.6–7.5)|
|50–64||12 (8.7–16)||12 (8.5–16)|
|>65||16.6 (14–19)||17 (14–19)|
|Rate at which patients complete antimicrobial drug course||0.22 (0.17–2.29)||0.22 (0.17–2.29)||(29)|
|Rate at which recurrence develops in recovered patients||0.13 (0.24–1)||0.2 (0.32–1.05)||(30)|
|Rate at which patients not receiving antimicrobial drugs at increased risk for CDI revert to normal risk||0.038 (0.012–0.062)||0.033 (0.014–0.056)||(15)|
|Rate of recovery from CDI||0.099 (0.090–0.11)||0.099 (0.092–0.11)||(22)|
|Probability that a patient recovering from primary CDI will have >1 recurrence||22 (13–34)||24 (15–36)||(16,17)|
|Probability that a patient recovering from a first recurrence will have a second recurrence||33 (19–48)||34 (20–48)||(16,17)|
|Probability that a patient recovering from multiple recurrences will have an additional recurrence||56 (42–70)||56 (41–68)||(17,18)|
|Relative risk for CDI developing while a patient receives antimicrobial drugs||8.9 (4.9–13.)||8.3 (4.2–12)||(2,15)|
|Relative risk for CDI among persons 50–65 y of age vs. those <50 y of age||2.2 (1.4–3.4)||2.2 (1.5–3.0)||(31)|
|Relative risk for CDI among persons >65 y of age compared with those <50 y of age||2.9 (1.9–4.4)||3.2 (2.1–4.3)||(31)|
|Spontaneous clearance of asymptomatic C. difficile colonization||0.020 (0.015–0.025)||0.021 (0.016–0.026)||(32)|
|All-cause fraction of community-onset CDI in patients who are hospitalized||0.26 (0.23–0.28)||0.26 (0.23–0.28)||(26)|
|All-cause fraction of LTCF-onset CDI in patients who are hospitalized||0.27 (0.23–0.32)||0.27 (0.23–0.32)||(27)|
|Increased attributable length of stay for hospitalized patients with CDI||3.1 (2.3–4.0)||3.1 (2.3–4.1)||(19–21)|
|Effectiveness of enhanced infection control measures in reducing transmission||53 (37–72)||52 (37–68)||(22,23)|
|Probability that a patient with CDI is properly identified and given enhanced infection control measures||0.96 (0.93–0.99)‡||0.96 (0.94–0.99)||(24,25)|
|Antimicrobial drug use rates|
|Prescription rate among persons in community||(33,34)|
|<50||0.0013 (0.00095–0.0017)||0.0014 (0.00095–0.0018)|
|50–64||0.0014 (0.00097–0.0018)||0.0014 (0.00097–0.0017)|
|>65||0.0017 (0.0013–0.0021)||0.0017 (0.0013–0.0022)|
|Prescription rate among patients in hospital||0.37 (0.22–0.66)||0.37 (0.21–0.68)||(29)|
|Prescription rate among patients in LTCF||0.0054 (0.0027–0.009)||0.0052 (0.0026–0.0087)||(35)|
*CDI, C. difficile infection; LTCF, long-term care facility.
†Parameter rates are per day unless otherwise indicated.
‡A total of 73% of sites initiated protocols before laboratory confirmation and 27% initiated protocols after confirmation. Sensitivity was 86% for laboratory tests, which yielded an effective diagnosis rate of 0.73 + 0.27 × 0.86 = 0.96.
- Zilberberg MD. Increase in adult Clostridium difficile–related hospitalizations and case-fatality rate, United States, 2000–2005. Emerg Infect Dis. 2008;14:929–31.
- Deshpande A, Pasupuleti V, Thota P, Pant C, Rolston DD, Sferra TJ, Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. J Antimicrob Chemother. 2013;68:1951–61 .
- Svenungsson B, Burman LG, Jalakas-Pornull K, Lagergren A, Struwe J, Akerlund T. Epidemiology and molecular characterization of Clostridium difficile strains from patients with diarrhea: low disease incidence and evidence of limited cross-infection in a Swedish teaching hospital. J Clin Microbiol. 2003;41:4031–7.
- Walker AS, Eyre DW, Wyllie DH, Dingle KE, Harding RM, O’Connor L, Characterisation of Clostridium difficile hospital ward–based transmission using extensive epidemiological data and molecular typing. PLoS Med. 2012;9:e1001172.
- Norén T, Akerlund T, Bäck E, Sjöberg L, Persson I, Alriksson I, Molecular epidemiology of hospital-associated and community-acquired Clostridium difficile infection in a Swedish county. J Clin Microbiol. 2004;42:3635–43.
- Curry SR, Muto CA, Schlackman JL, Pasculle AW, Shutt KA, Marsh JW, Use of multilocus variable number of tandem repeats analysis genotyping to determine the role of asymptomatic carriers in Clostridium difficile transmission. Clin Infect Dis. 2013;57:1094–102.
- Lanzas C, Dubberke ER, Lu Z, Reske KA, Gröhn YT. Epidemiological model for Clostridium difficile transmission in healthcare settings. Infect Control Hosp Epidemiol. 2011;32:553–61.
- Otten AM, Reid-Smith RJ, Fazil A, Weese JS. Disease transmission model for community-associated Clostridium difficile infection. Epidemiol Infect. 2010;138:907–14.
- Gerding DN, Johnson S. Management of Clostridium difficile infection: thinking inside and outside the box. Clin Infect Dis. 2010;51:1306–13.
- Starr JM, Rogers TR, Impallomeni M. Hospital-acquired Clostridium difficile diarrhoea and herd immunity. Lancet. 1997;349:426–8.
- Lofgren ET, Moehring RW, Anderson DJ, Weber DJ, Fefferman NH. A mathematical model to evaluate the routine use of fecal microbiota transplantation to prevent incident and recurrent Clostridium difficile infection. Infect Control Hosp Epidemiol. 2014;35:18–27.
- Starr JM, Campbell A, Renshaw E, Poxton IR, Gibson GJ. Spatio-temporal stochastic modelling of Clostridium difficile. J Hosp Infect. 2009;71:49–56.
- Yakob L, Riley TV, Paterson DL, Clements AC. Clostridium difficile exposure as an insidious source of infection in healthcare settings: an epidemiological model. BMC Infect Dis. 2013;13:376.
- Rubin MA, Jones M, Leecaster M, Khader K, Ray W, Huttner A, A simulation-based assessment of strategies to control Clostridium difficile transmission and infection. PLoS ONE. 2013;8:e80671.
- Dial S, Kezouh A, Dascal A, Barkun A, Suissa S. Patterns of antibiotic use and risk of hospital admission because of Clostridium difficile infection. CMAJ. 2008;179:767–72.
- Lowy I, Molrine DC, Leav BA, Blair BM, Baxter R, Gerding DN, Treatment with monoclonal antibodies against Clostridium difficile toxins. N Engl J Med. 2010;362:197–205 .
- Figueroa I, Johnson S, Sambol SP, Goldstein EJC, Citron DM, Gerding DN. Relapse versus reinfection: recurrent Clostridium difficile infection following treatment with fidaxomicin or vancomycin. Clin Infect Dis. 2012;55(Suppl 2):S104–9.
- McFarland LV. A randomized placebo-controlled trial of Saccharomyces boulardii in combination with standard antibiotics for Clostridium difficile disease. JAMA. 1994;271:1913–8.
- Kyne L, Hamel MB, Polavaram R, Kelly CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis. 2002;34:346–53.
- Dubberke ER, Butler AM, Reske KA, Agniel D, Olsen MA, D’Angelo G, Attributable outcomes of endemic Clostridium difficile–associated disease in nonsurgical patients. Emerg Infect Dis. 2008;14:1031–8.
- O’Brien JA, Lahue BJ, Caro JJ, Davidson DM. The emerging infectious challenge of Clostridium difficile–associated disease in Massachusetts hospitals: clinical and economic consequences. Infect Control Hosp Epidemiol. 2007;28:1219–27.
- Jarvis WR, Schlosser J, Jarvis AA, Chinn RY. National point prevalence of Clostridium difficile in US health care facility inpatients, 2008. Am J Infect Control. 2009;37:263–70.
- Harris AD, Pineles L, Belton B, Johnson JK, Shardell M, Loeb M, Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA. 2013;310:1571–80 .
- Wilkinson K, Gravel D, Taylor G, McGeer A, Simor A, Suh K, Infection prevention and control practices related to Clostridium difficile infection in Canadian acute and long-term care institutions. Am J Infect Control. 2011;39:177–82.
- Sloan LM, Duresko BJ, Gustafson DR, Rosenblatt JE. Comparison of real-time PCR for detection of the tcdC gene with four toxin immunoassays and culture in diagnosis of Clostridium difficile infection. J Clin Microbiol. 2008;46:1996–2001.
- Chitnis AS, Holzbauer SM, Belflower RM, Winston LG, Bamberg WM, Lyons C, Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011. JAMA Intern Med. 2013;173:1359–67.
- Pawar D, Tsay R, Nelson DS, Elumalai MK, Lessa FC, Clifford McDonald L, Burden of Clostridium difficile infection in long-term care facilities in Monroe County, New York. Infect Control Hosp Epidemiol. 2012;33:1107–12.
- Hensgens MP, Goorhuis A, Dekkers OM, van Benthem BH, Kuijper EJ. All-cause and disease-specific mortality in hospitalized patients with Clostridium difficile infection: a multicenter cohort study. Clin Infect Dis. 2013;56:1108–16.
- Polk RE, Hohmann SF, Medvedev S, Ibrahim O. Benchmarking risk-adjusted adult antibacterial drug use in 70 US academic medical center hospitals. Clin Infect Dis. 2011;53:1100–10.
- McFarland LV, Elmer GW, Surawicz CM. Breaking the cycle: treatment strategies for 163 cases of recurrent Clostridium difficile disease. Am J Gastroenterol. 2002;97:1769–75.
- Dubberke ER, Reske KA, Olsen MA, McMullen KM, Mayfield JL, McDonald LC, Evaluation of Clostridium difficile–associated disease pressure as a risk factor for C. difficile-associated disease. Arch Intern Med. 2007;167:1092–7.
- Simor AE, Yake SL, Tsimidis K. Infection due to Clostridium difficile among elderly residents of a long-term-care facility. Clin Infect Dis. 1993;17:672–8.
- Zhang Y, Steinman MA, Kaplan CM. Geographic variation in outpatient antibiotic prescribing among older adults. Arch Intern Med. 2012;172:1465–71.
- Hicks LA, Taylor TH, Hunkler RJ. Outpatient antibiotic prescribing, 2010. N Engl J Med. 2013;368:1461–2.
- Mylotte JM. Antimicrobial prescribing in long-term care facilities: prospective evaluation of potential antimicrobial use and cost indicators. Am J Infect Control. 1999;27:10–9.
- McDonald LC, Owings M, Jernigan D. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996–2003. Emerg Infect Dis. 2006;12:409–15.
- Galdys AL, Nelson JS, Shutt KA, Schlackman JL, Pakstis DL, Pasculle AW, Prevalence and duration of asymptomatic Clostridium difficile carriage among healthy subjects in Pittsburgh, Pennsylvania. J Clin Microbiol. 2014;52:2406–9.
- Alasmari F, Seiler SM, Hink T, Burnham C-AD, Dubberke ER. Prevalence and risk factors for asymptomatic Clostridium difficile carriage. Clin Infect Dis. 2014;59:216–22.
- Loo VG, Bourgault A-M, Poirier L, Lamothe F, Michaud S, Turgeon N, Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med. 2011;365:1693–703.
- Metropolis N, Rosenbluth AW, Rosenbluth MN, Teller AH, Teller E. Equation of state calculations by fast computing machines. J Chem Phys. 1953;21:1087.