Improvements in Understanding C diff for Health Care Facility-Associated Cases

There have been some improvements among rates of healthcare facility-associated Clostridioides difficile (C diff), according to a new JAMA Network Open report. However, a better understanding of community-acquired C diff is needed to prevent infection in the future.

Investigators from Duke University Medical Center conducted a long-term multicenter study that reviewed records of more than 2 million admitted patients in order to assess trends in incidence of health care facility-acquired and community-acquired C diff. The patients were located in a network of 43 hospitals mostly in the Southeastern United States between 2013 and 2017.

Of that patient population, the investigators identified 21,254 C diff cases. The median age for patients with C diff infection was 69 years; almost 60% were female. Patients with health care facility-acquired C diff infection were often older, and male compared to those with community-acquired C diff infection, the study authors learned.

C diff is still a leading health care facility-associated infection, the study authors wrote. In their case, they wanted to specifically examine the NAP1 strain of C diff to expand what is known about the infection’s epidemiologic profile, which could then inform targeted prevention strategies.

“We were most intrigued by the rather dramatic increase in the proportion of C diff cases originating in the community,” study author Nicholas Turner, MD, a medical instructor in the Division of

Nicholas Turner, MD

Infectious Diseases at Duke, told Contagion®. “While ours is not the first paper to note this increase, we do think it adds the advantages of a large-scale, robust dataset with careful adjustment for the increasing use of PCR-based testing.”

The median total C diff incidence was 7.9 cases per 1000 admissions in 2013, which was found to have increased slightly to 9.3 cases per 1000 admissions by 2017, the study authors found. Meanwhile, the median community-acquired C diff incidence increased from 3.7 per 1000 admissions in 2013 to 5.6 per 1000 admissions by 2017. Both sets of data demonstrated a possible infection point occurring in 2015, the study authors noted, though it may have been due to facilities moving to PCR-based testing.

“While our study does not get into the exact causes for the observed increase in proportion of C diff cases acquired in the community (that will take some more epidemiologic detective work), I think it is a call to action for outpatient providers to begin thinking about C diff prevention,” said Turner, who added that understanding the reservoirs for C diff transmission outside of the hospital setting is a “crucial next step.” Some of these other sources that deserve a closer look include animals, soil, and water, he said.

The investigators also determined that 26 hospitals reported the NAP1 C. diff strain, where cases attributed to the strain was 22.6%. Despite an increase from 22.5% in 2013 to 24.6% in 2017, the study authors said this proportion varied widely among facilities. There was no statistically significant increase over time among NAP1 cases in either community-acquired to healthcare facility-acquired C diff.

“With all of the opportunities for antibiotics to be given in clinics, ambulatory surgery centers, even dental offices, choosing the most targeted antibiotic, for the shortest effective duration, and only when needed, [antibiotic stewardship] remains the best way to maintain healthy gut flora and avoid C diff…” Turner concluded.