CDI Remains a Major, ‘Multifactorial’ Challenge

Though Clostridioides difficile infection (CDI) is often discussed in the context of efforts to lower the risk of healthcare-associated infections, a new review article notes that CDI is a problem both within and without healthcare settings, and the high rates of recurrence can create a formidable burden on patients.

The new report outlines some of the “unseen and underappreciated” consequences of CDI, and calls for more efforts to be made to support patients and prevent infections. The review was published in BMC Infectious Diseases.

Glenn Tillotson, PhD, FIDSA, FCCP, of GSTMicro, LCC, and colleagues began by outlining shifts in the epidemiology of CDI. They said the overall burden of CDI is estimated to have decreased by 24% between 2011 and 2017. The COVID-19 pandemic, and the heightened spotlight on infection control that accompanied it, may have further decreased CDI rates, though Tillotson and colleagues said the CDC has not yet released definitive data.

However, those decreases seem to be driven by reductions in healthcare-associated cases of CDI. Community-associated cases seem to be on the rise, and in 2019 made up the majority of cases (53%), the authors noted.

“Given the changing epidemiology of CDI, continued efforts are required to improve infection prevention and diagnostic and antibiotic stewardship not only in inpatient settings, but also in outpatient settings,” they wrote.

One reason CDI is so problematic is that, for many patients, the fight against CDI is a war, rather than a single battle. About one-third (35%) of people with CDI will experience a recurrence after their first case, and 60% of patients who experience a recurrence will experience at least one more recurrence. In the US alone, recurrence accounts for an estimated 75,000-175,0000 cases of CDI per year. A number of risk factors increase a patient’s risk of CDI or recurrent CDI (rCDI), including antibiotic use, being female, being immunosuppressed, and having comorbidities such as renal disease, inflammatory bowel disease, and diabetes, the authors noted. However, patients with community-acquired CDI tend to be somewhat younger than patients with healthcare-associated cases.

Estimates suggest that between 6-11% of patients with CDI will die from the infection within 30 days, but the risk of death is higher with recurrences, the authors said. Complications, such as sepsis, are also common.

However, Tillotson and colleagues said it is important to understand that the impact of CDI is much broader than its epidemiology.

“Various studies have reported the CDI and rCDI have significant detrimental effects on patients’ quality of life that can have long-lasting and emotional impacts,” they noted.

One study found 31% of people with rCDI are “very worried” about infecting others, 26% said they felt like prisoners in their home or hospital room, and 22% said they were unwilling or unable to eat.

Patients with CDI also reported spending an average of $4,355 on out-of-pocket healthcare expenses for their current case, and $8,695 on previous bouts.

The infection also creates a major burden on the healthcare system itself. A previous study found people with CDI stay in the hospital for 8 days, on average, for their index episode, and 9.3 days for recurrent episodes. Total inpatient costs associated with CDI are estimated to be around $5 billion per year, the authors said, and rCDI is estimated to cost the healthcare system $2.8 billion per year.

Tillotson and colleagues said their review shows that managing patients with CDI involves multiple facets, including an acknowledgement of the psychological, social, and economic effects of the disease.

“From a health resource and healthcare institution perspective, efforts should be made to reduce costs and fiscal losses due to reimbursement penalties and efforts should be directed at preventing rCDI and community-acquired CDI,” they said.