Community-Onset Clostridium difficile Infections on the Rise in VHA

The study could reveal a trend in development and risk of CDI outside the VHA system.

Kelly R. Reveles, PharmD, PhD

A retrospective cohort study of adult US National Veterans Health Administration (VHA) beneficiaries with clostridium difficile infection (CDI) has discovered a rise in community-onset CDI infections.

The study led by Kelly R. Reveles, PharmD, PhD, with the College of Pharmacy at the University of Texas, Austin, reports that although health care facility-onset CDI (HCFO-CDI) remains a predominant type of CDI, and carries with it higher rates of severity and morality, there has been a significant decrease in HCFO-CDIs for adult VHA beneficiaries.

This decrease in HCFO-CDIs is good news for patients and healthcare providers, but as HCFO-CDI numbers have dropped, there has been an increase in community-onset CDI.

Reveles and colleagues report that between 2003­—2014 the proportion of HCFO-CDIs among US veterans has fallen from 73.5% (2003) to 53.2% (2014) for VHA beneficiaries due to advances in and emphasis on infection control within those facilities.

In an interview with MD Magazine, Reveles stated that "advances in antimicrobial stewardship and infection control practices in hospitals have likely contributed to this trend" but the rise in numbers of community-onset CDI indicates that efforts targeting community CDI are greatly needed.

The retrospective cohort study included information on 30,326 patients treated for CDI during inpatient or outpatient care in VHA facilities between Oct. 1, 2002 and Sept. 30, 2014. Data was obtained from the Veterans Affairs Informatics and Computing Infrastructure for patients between 18—89 years of age who tested positive for first-episode CDI (indicating no prior diagnosis of CDI to exclude recurrent CDI patients).

Demographic data was collected on age, sex, race, and ethnicity, and CDI onset data were categorized into HCFO-CDI, community-onset health care facility-associated CDI (CO-HCFA-CDI), or community-onset CDI (CA-CDI) based on prior hospitalization records associated with CDI treatment.

CO-HCFA-CDI was defined by researchers on the presence of a prescription for a CDI therapy as an outpatient, or on day 1 or 2 of hospitalization, plus 1 or more prior hospitalizations occurring within 90 days preceding CDI diagnosis.

HCFO-CDI was defined as infection therapy on or after day 3 of hospitalization.

CA-CDI was defined by CDI therapy that occurred on day 1 or 2 of hospitalization, but without any prior hospitalization.

Data showed that 18, 260 patients fell into the definition of HCFO-CDI (60.2% overall, p < .0001), and that those patients had the highest rates of severe CDI (70.2%, 95% CI), higher mortality rates (30-day=24.5%; 60-day=29.4%; 90-day=32.6%), and longer hospital stays (62.5% ≥ 14 days), but saw lower rates of CDI recurrence than patients with CO-HCFA-CDI and patients with CO-CDI.

Data showed that patients with CO-HCFA-CDI (n=6, 236) had a 61.1% (95% CI) rate of severe CDI, lower mortality rates (30-day=18.5%; 60-day=23.7%; 90-day=26.7%) than HCFO-CDI, and significantly shorter hospital stays (28.2% ≥ 14 days) than patients with HCFO-CDI. However, data showed that patients with CO-HCFA-CDI had the highest rates of CDI recurrence (30-day=20.6%; 60-day=26.3%; 90-day=28.1%).

Patients categorized with CA-CDI (n= 5, 830) saw the lowest risk for development of severe CDI (50%, 95% CI), reduced mortality rates (30-day=12.4%; 60-day=14.8%; 90-day=16.2%), and shorter hospital stays (21.3% ≥14 days), but also saw an increased risk of recurrence in comparison to HCFO-CDI (30-day=19%; 60-day=23.3%; 90-day=24.8%).

Reveles and colleagues hypothesize that the shift in location of CDI development from health care facilities to community settings could be 2-fold, resulting in part from increased use of high-risk antibiotics like fluoroquinolones in the community, and in part as a result of an "increase in the number of elderly patients admitted to long-term care facilities" where age of residents and close-living can increase risk factors for CDI.

MD Magazine asked Reveles to comment on what might be done to reduce risk the risk of CA-CDI and CO-HCFA-CDI. In an interview, Reveles suggested that prevention of CDI in long-term care facilities requires a multi-faceted approach that includes reducing inappropriate antibiotic use, efficient diagnostic testing, and proper infection control procedures (e.g., hand hygiene, room disinfection, use of private rooms).

Reveles stated that with an increased effort to prevent CDI in long-term care facilities, the rate of CDI is likely to decline overall; however, these facilities will still need considerable attention for preventative efforts since residents are often inherently at high-risk for CDI due to advanced age and underlying medical conditions.

The study, although limited to VHA patients, could reveal a trend in development and risk of CDI outside the VHA system, but further research is required to determine data on CDI development and risks in separate settings.

"Understanding the burden of CDI in various settings can help direct public health and other preventative resources where they are needed the most,” Reveles noted.

An increased focus on antimicrobial stewardship programs are predominately formed within hospitals and have likely contributed to reduced hospital-onset CDI rates which is in contrast to antibiotic use in outpatient settings where it’s common for inappropriate.

Due to the shift in CDI from HCFO-CDI to CA-CDI Reveles’ study revealed that outpatient stewardship programs should be developed to help prevent CDI in the community and long-term care facilities.

The article, "Shift to community-onset Clostridium difficile infection in the national Veterans Health Administration, 2003-2014" appeared in the American Journal of Infection Control on Nov. 7, 2017.

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