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Incidence of Polymerase Chain Reaction–Diagnosed Clostridium difficile in a Large High-Risk Cohort, 2011-2012

      Abstract

      Objective

      To describe incidence rates (IRs) of polymerase chain reaction (PCR)–diagnosed Clostridium difficile infection (CDI) in a large high-risk cohort.

      Patients and Methods

      Members of Kaiser Permanente Southern California 1 year or older who were admitted to any of 14 Kaiser Permanente hospitals from January 1, 2011, through December 31, 2012, were included in the study. The CDI cases were identified by PCR in the inpatient and outpatient settings. The CDI IRs per 10,000 inpatient-days are estimated by year, surveillance category, age, sex, race/ethnicity, and Charlson comorbidity index. Recurrence rates are presented by age, sex, and race/ethnicity. Death and colectomy in the 30 days after CDI diagnosis, white blood cell count, and serum creatinine level are assessed.

      Results

      Among 268,655 patients, 4286 (1.6%) had CDI. Among these patients, 671 (15.7%) had recurrent infections. The IR was highest among community-onset, health care facility–associated infections (11.1 per 10,000 inpatient-days). The CDI IRs differed by age, sex, and race/ethnicity. Overall, 528 patients (12.3%) died within 30 days of a positive CDI test result. The CDI IRs increased 34% with implementation of PCR testing.

      Conclusion

      Increasingly, PCR is being used because of its higher diagnostic sensitivity. Reassessing the epidemic using PCR updates our understanding of CDI risk. Our capacity to identify patients presenting in the outpatient setting after discharge provides a more accurate picture of health care–associated CDI rates, particularly because the community appears to assume an increasing role in CDI onset and possibly transmission. The CDI burden differs by race, comorbidity, sex, and previous health care use. The detected increase in CDI incidence after transitioning to PCR diagnosis was modest compared with previous studies.

      Abbreviations and Acronyms:

      CDI (Clostridium difficile infection), ED (emergency department), EIA (enzyme immunoassay), HCF (health care facility), HIV (human immunodeficiency virus), ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), IR (incidence rate), KPSC (Kaiser Permanente Southern California), PCR (polymerase chain reaction), WBC (white blood cell)
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      References

        • Kelly C.P.
        • Pothoulakis C.
        • LaMont J.T.
        Clostridium difficile colitis.
        N Engl J Med. 1994; 330: 257-262
        • Gorbach S.L.
        Antibiotics and Clostridium difficile.
        N Engl J Med. 1999; 341: 1690-1691
        • O'Connor J.R.
        • Johnson S.
        • Gerding D.N.
        Clostridium difficile infection caused by the epidemic BI/NAP1/027 strain.
        Gastroenterology. 2009; 136: 1913-1924
        • Lessa F.C.
        • Gould C.V.
        • McDonald L.C.
        Current status of Clostridium difficile infection epidemiology.
        Clin Infect Dis. 2012; 55: S65-S70
        • Kyne L.
        • Hamel M.B.
        • Polavaram R.
        • Kelly C.P.
        Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile.
        Clin Infect Dis. 2002; 34: 346-353
        • Kutty P.K.
        • Woods C.W.
        • Sena A.C.
        • et al.
        Risk factors for and estimated incidence of community-associated Clostridium difficile infection, North Carolina, USA.
        Emerg Infect Dis. 2010; 16: 197-204
        • Kuntz J.L.
        • Johnson E.S.
        • Raebel M.A.
        • et al.
        Epidemiology and healthcare costs of incident Clostridium difficile infections identified in the outpatient healthcare setting.
        Infect Control Hosp Epidemiol. 2012; 33: 1031-1038
        • Chitnis A.S.
        • Holzbauer S.M.
        • Belflower R.M.
        • et al.
        Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011.
        JAMA Intern Med. 2013; 173: 1359-1367
        • Centers for Disease Control and Prevention
        Vital signs: preventing Clostridium difficile infections.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 157-162
        • McDonald L.C.
        • Coignard B.
        • Dubberke E.
        • et al.
        Recommendations for surveillance of Clostridium difficile-associated disease.
        Infect Control Hosp Epidemiol. 2007; 28: 140-145
        • Kufelnicka A.M.
        • Kirn T.J.
        Effective utilization of evolving methods for the laboratory diagnosis of Clostridium difficile infection.
        Clin Infect Dis. 2011; 52: 1451-1457
        • Gould C.V.
        • Edwards J.R.
        • Cohen J.
        • et al.
        Effect of nucleic acid amplification testing on population-based incidence rates of Clostridium difficile infection.
        Clin Infect Dis. 2013; 57: 1304-1307
        • Pepin J.
        • Valiquette L.
        • Alary M.E.
        • et al.
        Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity.
        CMAJ. 2004; 171: 466-472
        • Cohen S.H.
        • Gerding D.N.
        • Johnson S.
        • et al.
        Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).
        Infect Control Hosp Epidemiol. 2010; 31: 431-455
        • Koebnick C.
        • Langer-Gould A.M.
        • Gould M.K.
        • et al.
        Sociodemographic characteristics of members of a large, integrated health care system: comparison with US Census Bureau data.
        Perm J. 2012; 16: 37-41
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Centers for Disease Control and Prevention
        Multidrug-Resistant Organism & Clostridium difficile Infection (MDRO/CDI) Module.
        Division of Healthcare Quality Promotion, National Healthcare Safety Network, Atlanta, GA2013
        • VerLee K.E.
        • Finks J.L.
        • Wilkins M.J.
        • Wells E.V.
        Michigan Clostridium difficile hospital discharges: frequency, mortality, and charges, 2002-2008.
        Public Health Rep. 2012; 127: 62-71
        • Ricciardi R.
        • Rothenberger D.A.
        • Madoff R.D.
        • Baxter N.N.
        Increasing prevalence and severity of Clostridium difficile colitis in hospitalized patients in the United States.
        Arch Surg. 2007; 142: 624-631
        • Ricciardi R.
        • Nelson J.
        • Griffith J.L.
        • Concannon T.W.
        Do admissions and discharges to long-term care facilities influence hospital burden of Clostridium difficile infection?.
        J Hosp Infect. 2012; 80: 156-161
        • Dubberke E.R.
        • Butler A.M.
        • Yokoe D.S.
        • et al.
        Multicenter study of Clostridium difficile infection rates from 2000 to 2006.
        Infect Control Hosp Epidemiol. 2010; 31: 1030-1037
        • Moehring R.W.
        • Lofgren E.T.
        • Anderson D.J.
        Impact of change to molecular testing for Clostridium difficile infection on healthcare facility–associated incidence rates.
        Infect Control Hosp Epidemiol. 2013; 34: 1055-1061
        • Goldenberg S.D.
        Public reporting of Clostridium difficile and improvements in diagnostic tests.
        Infect Control Hosp Epidemiol. 2011; 32: 1231-1232
        • Grein J.D.
        • Ochner M.
        • Hoang H.
        • Jin A.
        • Morgan M.A.
        • Murthy A.R.
        Comparison of testing approaches for Clostridium difficile infection at a large community hospital.
        Clin Microbiol Infect. 2013;
        • Longtin Y.
        • Trottier S.
        • Brochu G.
        • et al.
        Impact of the type of diagnostic assay on Clostridium difficile infection and complication rates in a mandatory reporting program.
        Clin Infect Dis. 2013; 56: 67-73
        • Fong K.S.
        • Fatica C.
        • Hall G.
        • et al.
        Impact of PCR testing for Clostridium difficile on incident rates and potential on public reporting: is the playing field level?.
        Infect Control Hosp Epidemiol. 2011; 32: 932-933
        • Centers for Disease C, Prevention
        Surveillance for community-associated Clostridium difficile—Connecticut, 2006.
        MMWR Morb Mortal Wkly Rep. 2008; 57: 340-343
        • Centers for Disease Control and Prevention
        Severe Clostridium difficile–associated disease in populations previously at low risk—four states, 2005.
        MMWR Morb Mortal Wkly Rep. 2005; 54: 1201-1205
        • Garg S.
        • Mirza Y.R.
        • Girotra M.
        • et al.
        Epidemiology of Clostridium difficile–associated disease (CDAD): a shift from hospital-acquired infection to long-term care facility-based infection.
        Dig Dis Sci. 2013; 58: 3407-3412
        • Khanna S.
        • Pardi D.S.
        • Aronson S.L.
        • et al.
        The epidemiology of community-acquired Clostridium difficile infection: a population-based study.
        Am J Gastroenterol. 2012; 107: 89-95
        • Haines C.F.
        • Moore R.D.
        • Bartlett J.G.
        • et al.
        Clostridium difficile in a HIV-infected cohort: incidence, risk factors, and clinical outcomes.
        AIDS. 2013; 27: 2799-2807
        • Mwantembe O.
        • Gaillard M.C.
        • Barkhuizen M.
        • et al.
        Ethnic differences in allelic associations of the interleukin-1 gene cluster in South African patients with inflammatory bowel disease (IBD) and in control individuals.
        Immunogenetics. 2001; 52: 249-254
        • Missiha S.
        • Heathcote J.
        • Arenovich T.
        • Khan K.
        Canadian Pegasys Expanded Access Group. Impact of asian race on response to combination therapy with peginterferon alfa-2a and ribavirin in chronic hepatitis C.
        Am J Gastroenterol. 2007; 102: 2181-2188
        • Campbell F.
        • Appleton M.A.
        • Fuller C.E.
        • et al.
        Racial variation in the O-acetylation phenotype of human colonic mucosa.
        J Pathol. 1994; 174: 169-174
        • Planche T.D.
        • Davies K.A.
        • Coen P.G.
        • et al.
        Differences in outcome according to Clostridium difficile testing method: a prospective multicentre diagnostic validation study of C difficile infection.
        Lancet Infect Dis. 2013; 13: 936-945
        • Baker I.
        • Leeming J.P.
        • Reynolds R.
        • Ibrahim I.
        • Darley E.
        Clinical relevance of a positive molecular test in the diagnosis of Clostridium difficile infection.
        J Hosp Infect. 2013; 84: 311-315