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Multicenter Study
. 2019 Oct 2;2(10):e1914149.
doi: 10.1001/jamanetworkopen.2019.14149.

Epidemiologic Trends in Clostridioides difficile Infections in a Regional Community Hospital Network

Nicholas A Turner  1   2 , Steven C Grambow  3 , Christopher W Woods  1   4 , Vance G Fowler Jr  1 , Rebekah W Moehring  1   2 , Deverick J Anderson  1   2 , Sarah S Lewis  1   2
Affiliations
Multicenter Study

Epidemiologic Trends in Clostridioides difficile Infections in a Regional Community Hospital Network

Nicholas A Turner et al. JAMA Netw Open. .

Abstract

Importance: Clostridioides difficile infection (CDI) remains a leading cause of health care facility-associated infection. A greater understanding of the regional epidemiologic profile of CDI could inform targeted prevention strategies.

Objectives: To assess trends in incidence of health care facility-associated and community-acquired CDI among hospitalized patients over time and to conduct a subanalysis of trends in the NAP1 strain of CDI over time.

Design, setting, and participants: This long-term multicenter cohort study reviewed records of patients (N = 2 025 678) admitted to a network of 43 regional community hospitals primarily in the southeastern United States from January 1, 2013, through December 31, 2017. Generalized linear mixed-effects models were used to adjust for potential clustering within facilities and changing test method (nucleic acid amplification testing or toxin enzyme immunoassay) over time.

Main outcomes and measures: Clostridioides difficile infection incidence rates were counted as cases per 1000 admissions for community-acquired and total CDI cases or cases per 10 000 patient-days for health care facility-associated CDI. Long-term trends in the proportion of cases acquired in the community and in NAP1 strain incidence were also evaluated.

Results: A total of 2 025 678 admissions and 21 254 CDI cases were included (12 678 [59.6%] female; median [interquartile range] age, 69 [55-80] years). Median (interquartile range) total CDI incidence increased slightly from 7.9 (3.5-12.4) cases per 1000 admissions in 2013 to 9.3 (4.9-13.7) cases per 1000 admissions in 2017. After adjustment, the overall incidence of health care facility-associated CDI declined (incidence rate ratio [IRR], 0.995; 95% CI, 0.990-0.999; P = .03), whereas insufficient evidence was found for either an increase or a decrease in community-acquired CDI (IRR, 1.004; 95% CI, 0.999-1.009; P = .14). The proportion of cases classified as community acquired increased over time from a mean (SD) of 0.49 (0.28) in 2013 to 0.61 (0.26) in 2017 (odds ratio, 1.010 per month; 95% CI, 1.006-1.015; P < .001). Rates of the NAP1 strain of CDI varied widely between facilities, with no statistically significant change in NAP1 strain incidence over time in the community setting (IRR, 1.007; 95% CI, 0.994-1.021) or health care facility setting (IRR, 1.011; 95% CI, 0.990-1.032).

Conclusions and relevance: The findings suggest that, despite the modest improvement in health care facility-associated CDI rates, a better understanding of community-acquired CDI incidence is needed for future infection prevention efforts.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Turner reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Grambow reported receiving consulting fees from Gilead Sciences for serving on multiple data monitoring committees. Dr Woods reported receiving consulting fees from the following companies or organizations: Becton Dickinson, BioFire, BioMeme, bioMerieux, DARPA, Giner, IDbyDNA, Janus, MRI Global, NIH/Antibacterial Resistance Leadership Group (ARLG), NIH/ Vaccine and Treatment Evaluation Units, OpenBiome, Pfizer, Predigen Inc, Roche Molecular Sciences, RTI, and Sanofi. Dr Fowler reported receiving personal fees from Pfizer, Novartis, Galderma, Novadigm, Durata, Debiopharm, Genentech, Achaogen, Affinium, Medicines Co, Cerexa, Tetraphase, Trius, MedImmune, Bayer, Theravance, Cubist, Basilea, Affinergy, Janssen, xBiotech, Contrafect, Regeneron, and Destiny; grants from the NIH, MedImmune, Cerexa/Forest/Actavis/Allergan, Pfizer, Advanced Liquid Logics, Theravance, Novartis, Cubist/Merck, Medical Biosurfaces, Locus, Affinergy, Contrafect, Karius, Genentech, Regeneron, and Basilea; and personal fees from Green Cross, Cubist, Cerexa, Durata, Theravance, Debiopharm, and UpToDate during the conduct of the study; in addition, he reported holding a pending patent to sepsis diagnosis. Dr Moehring reported receiving grants from the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ) outside the submitted work. Dr Anderson reported receiving grants from the NIH National Institute of Allergy and Infectious Diseases (NIAID), AHRQ, and CDC as well as consulting fees from UpToDate Online outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow Diagram of Clostridioides difficile Infection (CDI) Cases
Figure 2.
Figure 2.. Observed Trends in Clostridioides difficile Infection (CDI) Incidence by Year in 43 Included Hospitals
Solid line indicates unadjusted median; gray shaded area, interquartile range.
Figure 3.
Figure 3.. Estimated Trends in Clostridioides difficile Infection (CDI) Incidence Rates Over Time for a Hospital
A and B, Shaded area represents 95% CI for the model, reflecting the degree of variation between health care facilities. Estimated community-acquired CDI incidence is reported for an urban community hospital with a mean of 941 admissions per month using nucleic acid amplification testing (NAAT) CDI testing. Estimated health care facility–associated CDI incidence is reported for an urban community hospital with a mean of 4078 patient-days per month using NAAT CDI testing. C, Scatterplot points represent mean proportion of community-acquired CDI cases compared with total CDI cases across all facilities for each month in the study period. The line indicates modeled proportion of community-acquired CDI cases using mixed-effects logistic regression; shaded area, 95% CI for the model.
See this image and copyright information in PMC

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