The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010

doi:10.1016/j.ajic.2014.06.011

American Journal of Infection Control

Volume 42, Issue 10, October 2014, Pages 1028-1032

https://doi.org/10.1016/j.ajic.2014.06.011 Get rights and content

Background

Clostridium difficile infection (CDI) incidence is a growing concern. This study provides national estimates of CDI over 10 years and identifies trends in mortality and hospital length of stay (LOS) among hospitalized adults with CDI.

Methods

We conducted a retrospective analysis of the US National Hospital Discharge Surveys from 2001-2010. Eligible cases included adults aged ≥18 years discharged from a hospital with an ICD-9-CM diagnosis code for CDI (008.45). Data weights were used to derive national estimates. CDI incidence rates were depicted as CDI discharges per 1,000 total adult discharges.

Results

These data represent 2.2 million adult hospital discharges for CDI over the study period. CDI incidence increased from 4.5 CDI discharges per 1,000 total adult discharges in 2001 to 8.2 CDI discharges per 1,000 total adult discharges in 2010. The overall in-hospital mortality rate was 7.1% for the study period. Mortality increased slightly over the study period, from 6.6% in 2001 to 7.2% in 2010. Median hospital LOS was 8 days (interquartile range, 4-14 days), and remained stable over the study period.

Conclusions

The incidence of CDI among hospitalized adults in the United States nearly doubled from 2001-2010. Furthermore, there is little evidence of improvement in patient mortality or hospital LOS.

Section snippets

Data source

We used data from the US National Hospital Discharge Surveys (NHDS). These surveys are conducted annually by the Centers for Disease Control and Prevention National Center for Health Statistics and provide a national probability sample of inpatients discharged from nonfederal, short-stay hospitals in the US. Hospital discharges are randomly sampled following a 3-stage sample design, including counties, hospitals, and discharges. Because of this complex sampling methodology, the survey data

Results

Overall, these data represent approximately 2.2 million adult CDI discharges from US hospitals from 2001-2010 (Table 1). Of these patients, 713,461 (33%) had a principal CDI diagnosis and 1,482,685 (67%) were classified as secondary CDI. The population of CDI patients was predominately female (59%) and white (86%). The median patient age was 75 years (interquartile range, 61-83 years) and 70% of patients were at least 65 years old (Table 1). Importantly, CDI was associated with significant

Discussion

Our study reveals the increasing burden of CDI among hospitalized adult patients in the US in recent years. Furthermore, little improvement was observed for clinically relevant outcomes, including patient mortality and hospital LOS.

Historical epidemiologic investigations demonstrated marked increases in CDI in North America and Europe beginning in the 1990s through the early 2000s3, 4, 5, 6; however, few studies have described these trends in more recent years. In 2012, the Agency for

Conclusions

The incidence of CDI among hospitalized adults in the US nearly doubled from 2001-2010. Furthermore, there is little evidence of improvement in patient mortality or hospital LOS. CDI treatment and prevention initiatives should remain a national priority.

References (37)

K.R. Daniels et al.
The United States' progress toward eliminating catheter-related bloodstream infections: incidence, mortality, and hospital length of stay from 1996 to 2008
Am J Infect Control
(2013)
M.H. Wilcox et al.
Incidence and impact of Clostridium difficile infection in the UK, 1993-1996
J Hosp Infect
(1998)
C.R. Frei et al.
Emergence of community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infections as a common cause of hospitalization in United States children
J Pediatr Surg
(2010)
G.E. Bignardi
Risk factors for Clostridium difficile infection
J Hosp Infect
(1998)
J.A. Linder et al.
Fluoroquinolone prescribing in the United States: 1995 to 2002
Am J Med
(2005)
M. Warny et al.
Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe
Lancet
(2005)
E.J. Kuijper et al.
Emergence of Clostridium difficile-associated disease in North America and Europe
Clin Microbiol Infect
(2006)
D.C. Burton et al.
Trends in catheter-associated urinary tract infections in adult intensive care units-United States, 1990-2007
Infect Control Hosp Epidemiol
(2011)
L.C. McDonald et al.
Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003
Emerg Infect Dis
(2006)
R. Ricciardi et al.
Increasing prevalence and severity of Clostridium difficile colitis in hospitalized patients in the United States
Arch Surg
(2007)

J. Pepin et al.

Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity

CMAJ

(2004)

J. Lucado et al.

Clostridium difficile infections (CDI) in hospital stays, 2009. HCUP Statistical Brief 124

(January 2012)

M. Rupnik et al.

Clostridium difficile infection: new developments in epidemiology and pathogenesis

Nat Rev Microbiol

(2009)

A.E. Simor et al.

Clostridium difficile in long-term-care facilities for the elderly

Infect Control Hosp Epidemiol

(2002)

P.K. Kutty et al.

Risk factors for and estimated incidence of community-associated Clostridium difficile infection, North Carolina, USA

Emerg Infect Dis

(2010)

C.P.R. Dennison

Design and operation of the National Hospital Discharge Survey: 1988 redesign

Vital Health Stat

(2000)

C.U. Oramasionwu et al.

Black race as a predictor of poor health outcomes among a national cohort of HIV/AIDS patients admitted to US hospitals: a cohort study

BMC Infect Dis

(2009)

C. Thomas et al.

Antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea: a systematic review

J Antimicrob Chemother

(2003)

Cited by (124)

Clostridioides difficile infection (CDI): A pan-European multi-center cost and resource utilization study, results from the Combatting Bacterial Resistance in Europe CDI (COMBACTE-CDI)
2023, Clinical Microbiology and Infection
Clostridioides difficile infection (CDI) is one of the leading nosocomial infections worldwide, resulting in a significantly increasing burden on the healthcare systems. However, Pan-European data about cost and resource utilization of CDI treatment do not exist.
A retrospective analysis within the Combatting Bacterial Resistance in Europe CDI project was conducted based on resource costs for inpatient treatment and productivity costs. Country-specific cost values were converted to EURO referred to 1 January, 2019 values. Differences in price levels for healthcare services among the participating countries were adjusted by using an international approach of the Organisation for Economic Co-operation and Development. As the study focused on patients with recurrent CDI, the observed study population was categorized into (a) patients with CDI but without CDI recurrence (case group), (b) patients with CDI recurrence (recurrence group), and (c) patients without CDI (control group).
Overall, 430 hospitalized patients from 12 European countries were included into the analysis between July 2018 and November 2018. Distribution of mean hospital length of stay and mean overall costs per patient between the case group, recurrence group, and control group were as follows: 22 days (95% CI 17–27 days) vs. 55 days (95% CI 17–94 days) vs. 26 days (95% CI 22–31 days; p 0.008) and € 15 242 (95% CI 10 593–19 891) vs. € 52 024 (95% CI 715–103 334) vs. € 21 759 (95% CI 16 484–27 035; p 0.010), respectively. The CDI recurrence rate during the observational period was 18%. Change escalation in CDI medication (OR 3.735) and treatment in an intensive care unit (OR 5.454) were found to be the most important variables associated with increased overall costs of patients with CDI.
Treatment of patients with recurrent CDI results in a significant burden. Prevention of CDI recurrences should be in focus of daily patient care to identify the most cost-effective treatment strategy.
Impact of the COVID-19 pandemic on the incidence of healthcare facility-onset Clostridioides difficile infection in hospitalized patients with sepsis: Interrupted time series analysis using Japanese Diagnosis Procedure Combination data
2023, Anaerobe
Healthcare facility-onset Clostridioides difficile infection (HO-CDI) is a major nosocomial infection associated with high mortality and healthcare costs. We aimed to determine if HO-CDI incidence decreased due to the COVID-19 pandemic. We hypothesized that the pandemic decreased HO-CDI as healthcare workers became more diligent in handwashing and sanitization.
In this retrospective cohort study, adult patients with sepsis hospitalized in general wards from January 2018 to February 2021 were identified using a nationwide Japanese administrative database. Patients were divided into two groups according to the hospitalization date (before and after the first declaration of a state of emergency). The primary outcome was a change in the level of the HO-CDI monthly incidence ratio (per 10000 patient-days).
Of the 49,156 eligible hospitalizations for sepsis, 41,870 were before and 7,283 were after the first state of emergency declaration. Interrupted time-series (ITS) analysis showed no significant difference in the HO-CDI incidence ratio after Japan's first state of emergency declaration (level change −1.0, 95% confidence interval (CI) −8.6 to 6.6, p = 0.8, slope change 0.06, 95% CI -0.17 to 0.3, p = 0.6). The overall HO-CDI incidence ratio was 3.86/10000 patient-days (interquartile range 2.97–4.53); higher incidence existed in subgroups with older adults or a lower Barthel index at admission.
No significant change in HO-CDI incidence was observed in patients with sepsis hospitalized in general wards before and after Japan's first state of emergency declaration. Our study revealed that HO-CDI in general wards in Japan had been consistently decreasing since before the COVID-19 pandemic.
Hospitalisations with infectious disease diagnoses in somatic healthcare between 1998 and 2019: A nationwide, register-based study in Swedish adults
2022, The Lancet Regional Health - Europe
Several studies indicate increasing hospitalisation rates for specific infectious diseases (IDs). Studies describing the entire ID spectrum are scarcer. Our aim was to describe hospital use with ID diagnoses in Swedish adults from 1998 to 2019.
All four-position codes in ICD-10 were reclassified as ID or non-ID diagnoses. Using data from the National Patient Register, age-standardised hospitalisation rates and average length-of-stay (LOS) was determined for hospitalisations with ID vs non-ID diagnoses in the primary position at discharge. The 22-year study period was divided into five periods that were compared using standardised rate ratios (SRR).
Annual hospitalisations with ID diagnoses increased from 115 thousand in 1998-2002 to 182 thousand in 2015-2019, for a rate increase from 17·4 to 23.0 per 1000 person-years, and a SRR (95%CI) of 1.32 (1.32-1.33). Concurrently, the hospitalisation rate with non-ID diagnoses decreased from 147 to 110, for a SRR of 0.75 (0.75-0.75). Average LOS decreased less for IDs than for non-IDs. Consequently, the proportion of hospital nights for which an ID was considered causing the hospitalisation increased from 11% to 21%. Persons aged 80+ years had the highest ID hospitalisation rate.
The increased hospital use with ID diagnoses suggests an increasing incidence of severe IDs as well as a changing case-mix of hospitalised patients. Given the anticipated demographic change, this trend is likely to persist. Healthcare systems will need to address IDs in a comprehensive and standardised way.
Governmental Funding of Research within the Clinical Sciences (ALF)
Role of high-risk antibiotic use in incidence of health-care-associated Clostridioides difficile infection in Quebec, Canada: a population-level ecological study
2021, The Lancet Microbe
The incidence of health-care-associated Clostridioides difficile infections has been declining in the Canadian province of Quebec since 2015. We examined whether changes in high-risk antibiotic use could account for this decrease, as reported in other jurisdictions.
We did a retrospective interrupted time-series analysis of 12 hospitals in the Canadian province of Quebec, representing a quarter of all health-care-associated C difficile infections in this region between April 1, 2012, and March 31, 2017. Data for high-risk antibiotic use (eg, amoxicillin–clavulanate, cephalosporins, fluoroquinolones, and clindamycin) in defined daily doses (DDDs) were extracted from local surveillance databases, and incidences of health-care-associated C difficile infections were extracted from provincial surveillance databases. We used hierarchical segmented Poisson regression to assess whether variations in rates of health-care-associated C difficile infections followed variations in antibiotic use.
Overall, 4455 health-care-associated C difficile infections and 6 281 960 patient-days were reported in the 12 participating hospitals, representing around a quarter of the provincial data. A 50% decrease in the annual incidence of health-care-associated C difficile infections was recorded between 2012–13 and 2016–17 (9·4 infections per 10 000 patient-days vs 4·7 infections per 10 000 patient-days), and a 67% decrease in the proportion of these infections due to the NAP1/027 strain of C difficile was seen (64% in 2013 vs 21% in 2017). In total, 1 266 960 DDDs of high-risk antibiotics were distributed during the study period. An increasing time trend was noted in high-risk antibiotic use, reaching a total of 223 DDDs per 1000 patient-days in 2016–17. An increase of one DDD per 1000 patient-days was associated with a 0·2% increase in the rate of health-care-associated C difficile infections in the following 4-week period. A significant change in incidence of health-care-associated C difficile infections persisted despite adjustment for high-risk antibiotic use, as shown by a significant residual step change (0·825, 95% CI 0·731–0·932) and change in trend (0·987, 0·980–0·994).
Changes in use of high-risk antibiotics do not entirely account for the sudden decrease in health-care-associated C difficile infections in the Canadian province of Quebec since 2015. Further studies are needed to understand factors implicated in the change in epidemiology of health-care-associated C difficile infections.
Institut National de Santé Publique du Québec.
Impact of COVID-19 prevention measures on risk of health care-associated Clostridium difficile infection
2021, American Journal of Infection Control
Clostridium difficile is the most common pathogen between health care-associated infections and its incidence has increased during the last years. lack of enough evidence about effective hygiene interventions to prevent this disease. Due to the coronavirus disease 2019 (COVID‑19) pandemic, several strategies to reduce microorganism spread were adopted in hospital setting. The objective of this study was to establish whether such strategies can reduce health care associated C difficile infection (HA-CDI) incidence. We found that, during the pandemic (2020) HA-CDI incidence was significantly lower with respect to the previous years. This work demonstrates that maintaining this level of attention regarding control activities related to prevention of microorganism transmission significantly reduce HA-CDI and related expenses in terms of health costs and human lives.
Systems Immunology and Infection Microbiology
2021, Systems Immunology and Infection Microbiology

View all citing articles on Scopus

: Conflicts of interest: None to report.

View full text

Major articleThe rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010

Background

Methods

Results

Conclusions

Section snippets

Data source

Results

Discussion

Conclusions

Am J Infect Control

J Hosp Infect

J Pediatr Surg

J Hosp Infect

Am J Med

Lancet

Clin Microbiol Infect

Trends in catheter-associated urinary tract infections in adult intensive care units-United States, 1990-2007

Infect Control Hosp Epidemiol

Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003

Emerg Infect Dis

Increasing prevalence and severity of Clostridium difficile colitis in hospitalized patients in the United States

Arch Surg

Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity

CMAJ

Clostridium difficile infections (CDI) in hospital stays, 2009. HCUP Statistical Brief 124

Clostridium difficile infection: new developments in epidemiology and pathogenesis

Nat Rev Microbiol

Clostridium difficile in long-term-care facilities for the elderly

Infect Control Hosp Epidemiol

Risk factors for and estimated incidence of community-associated Clostridium difficile infection, North Carolina, USA

Emerg Infect Dis

Design and operation of the National Hospital Discharge Survey: 1988 redesign

Vital Health Stat

Black race as a predictor of poor health outcomes among a national cohort of HIV/AIDS patients admitted to US hospitals: a cohort study

BMC Infect Dis

Antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea: a systematic review

J Antimicrob Chemother

Major article
The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010