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Hospital, community C. difficile transmission interconnected
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Although the rate of Clostridium difficile transmission is substantially lower in community vs. health care settings, the effects of community and hospital transmission on hospital-onset C. difficile infection are similar, according to the results of a simulation model. These findings led researchers to suggest that interventions that reduce community transmission could potentially reduce hospital-onset infections.
“To evaluate the relative role of asymptomatic hospital transmission, symptomatic hospital transmission, [long-term care facility] transmission, and community transmission, we integrated diverse clinical and epidemiologic data into a dynamic model of C. difficile transmission within and among hospitals, LTCFs, and community settings in the United States,” Erik R. Dubberke, MD, MSPH, and Margaret A. Olsen, PhD, MPH, both of Washington University School of Medicine in St. Louis, and colleagues wrote.
Erik R. Dubberke
Margaret A. Olsen
The researchers parameterized their model using national databases and calibrated it to C. difficile prevalence and CDI incidence in health care and community settings, aiming to provide estimates of infectivity in symptomatic and asymptomatic hospitalized patients, corresponding infectivity in LTCFs and the community, and risks for acquiring C. difficile in each setting.
Hospitalized patients with CDI were found to transmit C. difficile at a rate 15-fold (95% CI, 7.2-32) higher than that of asymptomatic patients.
“This high ratio indicates that a symptomatic patient with CDI contributes more to transmission than does an asymptomatically colonized patient, even after accounting for C. difficile protocols,” the researchers wrote. “This higher rate of transmission indicates that toxin-targeting treatments (such as vaccines); nontoxigenic C. difficile; and monoclonal antibodies, which might protect against symptomatic CDI but not against asymptomatic colonization, could be effective tools for reducing not only primary CDI cases but also for further transmission,” they added.
LTCF residents with CDI were found to transmit C. difficile to an uncolonized person at a rate of 27% (95% CI, 13-51) that of hospitalized patients, and individuals in the community with CDI were found to transmit C. difficile at a rate 0.1% (95% CI, 0.062- 0.2) that of hospitalized patients.
“Despite the lower community transmission rate, we found that because of the much larger pool of colonized persons in the community, interventions that reduce community transmission hold substantial potential to reduce hospital-onset CDI by reducing the number of patients entering the hospital with asymptomatic colonization,” the researchers wrote.
The researchers also observed that hospital CDI diagnosis rate, effectiveness of isolation, overall hospital hygiene and community transmission affects hospital-onset CDI.
Moreover, they observed that CDI incidence climbed with each unit increase in relative risk ratio for antimicrobial drug prescriptions in the hospital (160%; 95% CI, 98- 320), LTCF (33%; 95% CI, 13- 83) and in the community settings (6.4%; 95% CI, 3.9-13). “These results indicate that the effect of antimicrobial drug risk on CDI incidence is intertwined with C. difficile transmission dynamics, which differ between the hospital, LTCF, and community,” they wrote.
Based on these findings, the researchers concluded that C. difficile transmission in health care and community settings is intertwined, and that transmission dynamics in both settings should be considered when evaluating interventions and control strategies. – by Adam Leitenberger
Disclosure: Dubberke reports research support from Rebiotix, Microdermis, Merck and Sanofi-Pasteur, and has been a consultant for Sanofi-Pasteur, Rebiotix, Pfizer, Valneva, Merck, Summitt and Daiichi. Olsen reports research support from Sanofi-Pasteur and Pfizer and has been a consultant for Sanofi-Pasteur, Pfizer and Merck. Please see the full study for a list of all other researchers’ relevant financial disclosures.
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