Can the CDC Achieve Its C Diff Goal?: Public Health Watch

Can we make a difference in Clostridioides difficile?

That’s the stated aim of the US Centers for Disease Control and Prevention’s (CDC) plan to reduce incidence of C diff infections by 30% by 2020. The agency is coordinating this effort with the Centers for Medicare and Medicaid Services (CMS) and other federal entities.

“Infection prevention in acute-care hospitals has reduced rates of C diff and published guidance is useful to halt outbreaks in these settings,” Michelle Doll, MD, MPH, assistant professor, infectious disease and associate hospital epidemiologist, Virginia Commonwealth University School of Medicine, told Contagion®. “However, once the rate is controlled to a baseline or endemic low level, we lack guidance on how to further decrease the rate from there… [and] the next frontier will be to consider C diff reservoirs outside of acute-care hospitals and how to decrease acquisition events across continuums of care. CDC and other public health organizations do seem to be moving resources towards these opportunities.”

Indeed, the agency is spearheading a multi-pronged battle plan for this fight that includes education and outreach on national guidelines for infection control, building prevention initiatives in states with high C diff infection rates, working with health care facilities to identify and address barriers for C diff infection prevention, expanding implementation of antibiotic stewardship programs in all health care settings, and supporting research efforts to better understand the role of asymptomatic carriers, transmission dynamics, the patient’s microbiome, and environmental cleaning.

“The CDC is attacking the problem of C diff on multiple fronts,” Doll said. “They are doing surveillance to better understand the epidemiology and they are promoting antimicrobial stewardship or the judicious use of antibiotics in order to decrease disruptions to the microbiome and patient risk for infection. They are also promoting environmental cleaning and standard infection prevention practices to prevent transmission of organisms. The CDC’s efforts are a comprehensive attempt to understand and control this difficult pathogen.”

Difficult for sure. The CDC estimates that 223,900 hospitalized patients were diagnosed with C diff in 2017. Of these, more than 12,000 died. Although the numbers of infections appear to declining, incidence remains troubling high. C diff infection (CDI) has been linked with the administration of a number of widely used antibiotics, including amoxicillin, ceftriaxone, cephalexin, clindamycin, levofloxacin, meropenem, and piperacillin-tazobactam.

Unfortunately, if anything, the CDC estimates on the scope of the C diff challenge unintentionally work to minimize. To date, the agency’s counts don’t include cases in outpatient settings—ie, dentist’s offices—and community-acquired infections, and surveillance efforts are only starting to drill down to state-by-state incidence.

“Obviously, the CDC efforts are extremely beneficial, but certainly not sufficient,” noted Mohamed H Yassin, MD, PhD, Director, Infectious Diseases Division, and Medical Director, Infection Control, University of Pittsburgh Medical Center. “The steps taken by CDC are logic and reasonable but the problem is far from being fixed.”

Among the additional approaches Yassin and others would like to see are an improved definition to distinguish the source of CDI—community- versus health care-associated. And, he added, “The current definition is based on positive testing that occurs more than 2 calendar days after admission. This is not helpful to understand the exact source and reservoirs of CDI.”

He also suggested that there “needs to be better prospective characterization of high-risk patients with whole genome sequencing analysis” to determine the source of CDI and potential causes of its spread.

Even with all of these efforts, it is, as Doll said, “unlikely we will get to ‘zero’ infections of C diff, so long as we have vulnerable patients.” Still, there’s no harm trying.