Clostridium difficile Infection Incidence, Costs Reach Historic Highs

Clostridium difficile infection (CDI) took center stage in a report recently published in Morbidity and Mortality Weekly Report (MMWR) that stated "the incidence, deaths, and excess health care costs resulting from CDIs in hospitalized patients are all at historic highs."

According to the March 9 MMWR Vital Signs report, which analyzed population-based surveillance data from the CDC's Emerging Infections Program and other sources, hospital stays directly tied to CDIs tripled in the past decade and the number of hospitalized patients with any CDI discharge diagnosis more than doubled -- from about 139,000 to 336,600.

Still, the report found, many of these infections can be prevented, as demonstrated by a 20 percent reduction in hospital-onset CDIs among three state prevention programs conducted during a nearly two-year period.

Meanwhile, a study funded by the CDC and published in Infection Control and Hospital Epidemiology, illustrates an increasing trend in severity among cases of community-onset CDI. "A Multicenter Study of Clostridium difficile Infection-Related Colectomy, 2000-2006" (abstract) found that patients whose CDI symptoms start outside the hospital are much more likely to undergo colectomy because of severe infection.

In the study, researchers at five hospitals across the country collected CDI case data for six years, identifying 8,569 cases. Overall, 75 patients underwent colectomy because of severe CDI, a rate of 8.7 colectomies per 1,000 CDI cases. Notably, patients with community-onset CDI had colectomy rates four times higher than patients who developed symptoms while hospitalized. In addition, individuals who were age 65 or older were more likely to have a CDI-related colectomy.

The study findings come as no surprise to Doug Campos-Outcalt, M.D., M.P.A., of Phoenix.

"The community-onset cases that get to the hospital from the community are the severe ones, so it's expected that the colectomy rates would be higher," said Campos-Outcalt, who is chairman of the Department of Family, Community and Preventive Medicine at the University of Arizona College of Medicine, Phoenix, and the AAFP liaison to the U.S. Preventive Services Task Force. "The cases don't necessarily get counted unless they go to the hospital."

Long thought to be a predominantly hospital-associated infection, recent CDC data indicate that about 25 percent of CDI cases first show symptoms in hospital patients, while the other 75 percent of cases show up first in nursing home patients or people recently cared for in doctors' offices and clinics. Nearly half of all CDIs affect people younger than 65, but of the 14,000 deaths attributed to these infections each year, more than 90 percent occur in those 65 and older.

Regardless of where they originate, however, much of the blame for the high prevalence of CDIs can be traced to a single factor, says the CDC: overuse of antibiotics.

It's a problem with which family physician Rupal Trivedi, M.D., of Clayton, Mo., is all too familiar.

"From what I've seen in my practice at St. Louis University, there is a large population of antibiotic-associated C. diff. -- mostly in older hospital and nursing home patients who were discharged and had to be readmitted because of C. diff.," she told AAFP News Now.

Key to thwarting the rise in CDIs, said Trivedi, is educating patients about antibiotic misuse and advocating preventive measures.

"It falls on the family physician to use antibiotics judiciously in the outpatient setting and educate patients on the possibility of this debilitating condition and means for early detection and treatment in the event it does occur," she said.

R. Gregory Juckett, M.D., of Morgantown, W. Va., said CDI poses one of the most challenging infection control problems health care professionals face today.

"We should have a high degree of suspicion with any diarrheal illness so that cases will be quickly identified, isolated and treated," said Juckett, who is a professor of family medicine at West Virginia University in Morgantown.

Juckett said it is sobering how easily C. difficile spores can spread. According to the CDC, C. difficile spores are transferred to patients mainly through the hands of health care personnel who have touched a contaminated surface or item because the spores are not necessarily killed by hand sanitizer or hand-washing. The agency recommends that health care professionals wear gloves and gowns when treating patients with CDI and that room surfaces be cleaned with bleach or another Environmental Protection Agency-approved sporicidal disinfectant after a patient with a CDI has been treated there.

"Our overuse of antibiotics is largely responsible, so, in effect, we are reaping what we have sown," Juckett noted.

Concern about overuse of antibiotics is hardly a new development. The CDC launched its Get Smart for Healthcare campaign in 1995 to combat inappropriate antibiotic use. And although progress has been made, the agency reports, still about 50 percent of antibiotics given are not needed, raising the risk for CDIs and, in the long term, boosting the likelihood that drug-resistant bacteria emerge.

The Academy also recently addressed antibiotic overuse -- specifically, for acute mild-to-moderate sinusitis -- as part of the national Choosing Wisely campaign.

AAFP News Now Online Editor Matt Brown contributed to this story.