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CDI burden underestimated using only hospital inpatient surveillance
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New data suggest that a substantial number of Clostridium difficile infections may be missed if surveillance does not include outpatient settings or other nontraditional health care settings.
“Our research shows that traditional hospital-centric surveillance approaches likely lead to underestimation of the true burden of CDI,” the researchers wrote in Clinical Infectious Diseases. “Future hospital- and ambulatory-based surveillance systems that seek to estimate CDI incidence and recurrence should attempt to capture CDI episodes that are not associated with face-to-face interactions and may need to incorporate more syndrome-based approaches.”
Jennifer L. Kuntz PhD, of the Center for Health Research at Kaiser Permanente Northwest, and Philip M. Polgreen, MD, MPH, of University of Iowa Hospitals and Clinics, identified CDI cases from June 1, 2005 to Dec. 30, 2012, among patients of Kaiser Permanente Northwest. Cases in the inpatient setting were identified using the ICD-9 code for CDI (008.45). Cases in the outpatient setting were identified with the ICD-9 code or by positive C. difficile test and subsequent prescription for metronidazole or vancomycin. The researchers categorized the infection by the type of encounter during which the initial CDI indication occurred, and constructed surveillance estimates using different characteristics of patient encounters.
There were 8,024 cases of CDI during the study period, with an overall incidence of 15.9 CDIs per 10,000 patient-years of observation. Twenty-four percent of the CDI cases occurred during a hospitalization; 76% were observed in the outpatient setting. Seventy-nine percent of the cases were identified during face-to-face encounters, such as hospitalizations, ED visits, ambulatory care visits or other health care encounters. The remainder were identified in telephone or Internet encounters.
Using this data, the researchers found that if surveillance methods focused solely on hospitalized patients, only 24% of the entire CDI burden would be identified. If surveillance methods included only face-to-face encounters with a health care professional, then the 21% of cases identified in non-face-to-face encounters would be missed.
When using CDC surveillance definitions, 23.9% of the infections were hospital-acquired, and 76% were identified in the community setting. Among those identified in the community setting, 23.1% had a history of hospitalization within the previous 4 weeks; 39.7% were community-associated.
“The US incidence and recurrence of CDI has dramatically increased over the past 15 years,” the researchers wrote. “These data provide greater insight into population-level CDI incidence than hospital discharge data alone. Failure to capture cases that occur outside the hospital will not only lead to underestimates of population disease burden, but will also make it difficult to measure the impact of interventions to control CDI.”
Disclosure: The researchers report no relevant financial disclosures.
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