Clostridioides difficile formerly Clostridium difficile (C. difficile) Surveillance
Background
Clostridioides difficile (formerly Clostridium difficile) is an anaerobic, spore-forming, gram positive bacillus that produces two exotoxins: toxin A and toxin B. The bacterium is ubiquitous in nature and able to survive for long periods in the environment. Transmission of C. difficile occurs primarily in healthcare facilities where environmental contamination by spores and exposure to antimicrobial drugs are common. Patients are 7-10 times more likely to get C. difficile infection (CDI) while taking an antibiotic or during the month afterwards. The primary risk factor for development of CDI in healthcare settings is recent antimicrobial use. Other risk factors include being 65 and older, a recent stay at a hospital or nursing home, a weakened immune system, a serious underlying medical condition, an intensive care unit (ICU) admission, extended hospital stays, and having a previous CDI episode.
CDI has increased in incidence and severity, becoming the most common pathogen of healthcare-associated infections (HAI) and is a well-known cause of antibiotic associated diarrhea (AAD) and colitis. CDI accounts for 15 to 25% of all episodes of AAD. CDI causes almost half a million infections and estimated 29,300 deaths in the United States each year. About 1 in 6 patients who get CDI will get it again, in the subsequent 2-8 weeks. More than 80% of CDI related deaths occur in people 65 and older. CDI costs the health care system an estimated $3.2 billion annually. Healthcare facilities are strongly recommended to have antibiotic stewardship protocols and infection control practices in place to reduce the incidence of CDI.
Commonly considered to be hospital-acquired, rates of community-associated (CA) CDI have been increasing and currently make up more than 50% of cases reported. The sources of CA-CDI and the risks for developing CDI in community populations were previously thought to be low risk and are not well defined. Given the emergence and increasing significance of CA-CDI in public health, it is important to understand how poverty may influence the risk of CA-CDIs to improve not only the overall understanding of CDI epidemiology but also develop potential interventions that might be implemented at the community level.
Purpose
The Connecticut EIP C. difficile surveillance project monitors the incidence of healthcare (HA) and community-associated (CA) CDI at the population level, tracks changes over time, identifies at-risk populations, estimates disease burden and social determinants of health inequity. The Connecticut EIP collaborates with nine other EIP sites and CDC to characterize C. difficile strains responsible for CDI in the population under surveillance with a focus on strains from community-associated cases; and describes the epidemiology of CDI and generates hypotheses for future research activities. Ultimately, these efforts may provide healthcare facilities and providers with valuable guidance leading to an overall decline in CDI incidence.
Activities
Throughout 2009-2023, the Connecticut EIP CDI surveillance project used New Haven County as its catchment area. In June 2022, the United States Census Bureau approved a request from the State of Connecticut to adopt the state’s nine planning regions as county-equivalent geographic units to collect, tabulate, and disseminate census data. The catchment area for CDI surveillance beginning in 2024 will be South Central and Naugatuck planning regions. This catchment area has a population size of 1,019,904 residents, representing 28% of the state’s population. CDI surveillance does not use the entire state because the quantity of cases reported would not allow for high quality surveillance activities to be performed. This catchment area is demographically diverse with an estimated 63% of the population White, 19% Hispanic, and 14% Black. It is comprised of urban, suburban, and rural locations.
A list of all positive C. difficile tests will be evaluated to determine if in catchment and classification. A case is classified as community-onset if the C. difficile-positive stool was collected as an outpatient or within 3 days of hospital admission. A case is classified as healthcare-facility onset (HCFO) if it was a hospital-onset CDI (positive stool was collected >3 days after hospital admission) or a long-term care facility (LTCF) onset CDI (positive stool collected in a LTCF or from a LTCF resident admitted to a hospital). Community-onset cases are further classified as community-associated if there was no documentation of admission to a healthcare facility in the preceding 12 weeks; all other community-onset cases are considered community-onset healthcare-facility associated (CO-HCFA). Both the CO-HCFA cases and all HCFO cases are further classified as healthcare-associated CDI.
Each presumptive community-associated (CA) case, each community-onset healthcare associated (CO-HCFA) case, and a 10% sample of health-care onset (HCFO) cases will require a full chart review to complete the case report form. Select laboratories will save stool samples on cases of CDI for further laboratory evaluation including culture and toxinotype testing.
Recent Publications
- Association between Socioeconomic Status and Incidence of Community-Associated Clostridioides difficile Infection - United States, 2014-2015.Skrobarcek KA, Mu Y, Ahern J, Basiliere E, Beldavs ZG, Brousseau G, Dumyati G, Fridkin S, Holzbauer SM, Johnston H, Kainer MA, Meek J, Ocampo VLS, Parker E, Perlmutter R, Phipps EC, Winston L, Guh A. Clin Infect Dis. 2021 Aug 16. PMID: 33462596.
- Trends in incidence of long-term-care facility onset Clostridium difficile infections in 10 US geographic locations during 2011-2015.Guh AY, Mu Y, Baggs J, Winston LG, Bamberg W, Lyons C, Farley MM, Wilson LE, Holzbauer SM, Phipps EC, Beldavs ZG, Kainer MA, Karlsson M, Gerding DN, Dumyati G. Am J Infect Control. 2018 Jul; 2018 Jan 9. PMID: 29329918.
- Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study.Guh AY, Adkins SH, Li Q, Bulens SN, Farley MM, Smith Z, Holzbauer SM, Whitten T, Phipps EC, Hancock EB, Dumyati G, Concannon C, Kainer MA, Rue B, Lyons C, Olson DM, Wilson L, Perlmutter R, Winston LG, Parker E, Bamberg W, Beldavs ZG, Ocampo V, Karlsson M, Gerding DN, McDonald LC. Open Forum Infect Dis. 2017 Fall; 2017 Oct 26. PMID: 29732377.
- Burden of Nursing Home-Onset Clostridium difficile Infection in the United States: Estimates of Incidence and Patient Outcomes.Hunter JC, Mu Y, Dumyati GK, Farley MM, Winston LG, Johnston HL, Meek JI, Perlmutter R, Holzbauer SM, Beldavs ZG, Phipps EC, Dunn JR, Cohen JA, Avillan J, Stone ND, Gerding DN, McDonald LC, Lessa FC. Open Forum Infect Dis. 2016 Jan; 2016 Jan 18. PMID: 26798767.
- Identification of population at risk for future Clostridium difficile infection following hospital discharge to be targeted for vaccine trials.Baggs J, Yousey-Hindes K, Ashley ED, Meek J, Dumyati G, Cohen J, Wise ME, McDonald LC, Lessa FC. Vaccine. 2015 Nov 17; 2015 Oct 9. PMID: 26450660.
- Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection.Dantes R, Mu Y, Hicks LA, Cohen J, Bamberg W, Beldavs ZG, Dumyati G, Farley MM, Holzbauer S, Meek J, Phipps E, Wilson L, Winston LG, McDonald LC, Lessa FC. Open Forum Infect Dis. 2015 Sep; 2015 Aug 11. PMID: 26509182.
- Burden of Clostridium difficile infection in the United States.Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, Farley MM, Holzbauer SM, Meek JI, Phipps EC, Wilson LE, Winston LG, Cohen JA, Limbago BM, Fridkin SK, Gerding DN, McDonald LC. N Engl J Med. 2015 Feb 26. PMID: 25714160.
- Determinants of Clostridium difficile Infection Incidence Across Diverse United States Geographic Locations.Lessa FC, Mu Y, Winston LG, Dumyati GK, Farley MM, Beldavs ZG, Kast K, Holzbauer SM, Meek JI, Cohen J, McDonald LC, Fridkin SK. Open Forum Infect Dis. 2014 Sep; 2014 Jul 28. PMID: 25734120.
- NAP1 strain type predicts outcomes from Clostridium difficile infection.See I, Mu Y, Cohen J, Beldavs ZG, Winston LG, Dumyati G, Holzbauer S, Dunn J, Farley MM, Lyons C, Johnston H, Phipps E, Perlmutter R, Anderson L, Gerding DN, Lessa FC. Clin Infect Dis. 2014 May; 2014 Mar 5. PMID: 24604900.
- Clostridium difficile infection among children across diverse US geographic locations.Wendt JM, Cohen JA, Mu Y, Dumyati GK, Dunn JR, Holzbauer SM, Winston LG, Johnston HL, Meek JI, Farley MM, Wilson LE, Phipps EC, Beldavs ZG, Gerding DN, McDonald LC, Gould CV, Lessa FC. Pediatrics. 2014 Apr; 2014 Mar 3. PMID: 24590748.
Related Links
Centers for Disease Control and Prevention - Clostridium difficile Tracking
Centers for Disease Control and Prevention: Deadly Diarrhea: C. difficile Causes Immense Suffering, Death
Healthcare-Associated Infections-Community Interface Data Visualization Tool (HAICViz)
Project Contact
Danyel Olson, MPH
Project Coordinator
Connecticut Emerging Infections Program
One Church Street, 7th floor
New Haven, CT 06510
203-737-6978
danyel.olson@yale.edu
Clostridioides difficile (C.difficile) Surveillance Staff
- Maria Correa
- Anisa Linton
- Julia Ellman