Better Prevention of Clostridium Difficile Infections Needed

Most of the substantial increase in Clostridium difficile infections (CDIs) over the past decade in the United States is related to healthcare exposures that may be prevented by reducing unnecessary antibiotic use and interrupting transmission of C. difficile between patients, report investigators in the March 6 Morbidity and Mortality Weekly Report (MMWR) from the Centers for Disease Control and Prevention (CDC) [MMWR Weekly. 2012;61:1-6].

Over the past decade, the incidence of CDIs has risen substantially. Between 2000 and 2009, the number of primary diagnoses has more than tripled, from 33,000 to 111,000, and the number of hospitalized patients discharged with any CDI diagnoses has more than doubled from about 139,000 to 336,000. Although guidelines for CDI prevention in hospitals exist, the evidence for many of the recommendations in these guidelines is weak and the efficacy of these guidelines is not known. Also unknown is the relative burden of CDIs in hospital and nonhospital settings.

In this report, investigators used population-based data from 3 data sets to identify healthcare exposures for CDIs, determine the proportion of CDIs that occur outside of hospital settings, and assess whether prevention programs can reduce CDIs effectively. The 3 data sets used were the CDC’s Emerging Infections Program, the National Healthcare Safety Network (NHSN) Multidrug-Resistant Organism and Clostridium difficile Infection module for laboratory-identified (LabID)-CDI events, and data from 3 CDI prevention programs that included a total of 71 hospitals focused on measures to prevent intrahospital transmission of C. difficile in 3 states.

Data from the CDC’s Emerging Infections Program, which included 111 acute-care hospitals and 310 nursing homes, identified a total of 10,342 cases of CDIs in 2010 and found that most CDIs (94%) were related to healthcare exposures, with 75% having an onset outside of the hospitals. Data from the NHSN of LabID-CDI events reported in 2010 found a total of 42,157 incident LabID-CDI events reported. Of these events, 52% were already present in patients when admitted to the hospitals.

Examining the pooled data from the 3 prevention programs in 71 hospitals in 3 states, the study found a 20% reduction of CDIs over about 21 months with the implementation of prevention programs that included early reliable detection, isolation of infected persons, and enhanced environmental cleaning.

These findings highlight the need for improved prevention of CDIs, including focusing on good antibiotic stewardship, early and reliable detection of CDIs, isolation of patients who are symptomatic of CDIs, and reducing contamination of C. difficile on environmental surfaces in the healthcare setting.

The investigators emphasize the need for all stakeholders (clinicians, healthcare facilities, government officials, and patient safety groups) to work together to expand prevention strategies.

Beginning in 2013, the government will initiate an approach to improve prevention of CDIs in hospitals. All participating hospitals in the Centers for Medicare & Medicaid Services’ Inpatient Prospective Payment System Quality Reporting Program will be required to report facility-wide LabID-CDI events using NHSN to quality for their 2015 annual payment update.

Limitations of the study included a lack of data on antibiotic exposure, lack of data on potential underlying temporal trends in prevention program hospitals, and the lack of description of the various methods used to implement the prevention programs in the hospitals assessed.