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CDI decreases 36% in Canadian hospitals
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New estimates published in the Canadian Medical Association Journal show a 35.8% reduction in health care-associated Clostridium difficile infections in Canadian hospitals from 2009 to 2015.
The decline is largely attributed to infection control initiatives that were implemented in health care facilities across the country after major C. difficile infection (CDI) outbreaks occurred 10 to 15 years ago, according to Kevin C. Katz, MD, infection control consultant at North York General Hospital in Toronto, and colleagues. However, the data also indicate that a regression in a virulent strain known as NAP1 also played a role.
“Our findings suggest that, as the proportion of NAP1 strain isolates decreases in relation to all circulating strains, both the rate of health care-associated [CDI] and the number of severe cases can be expected to decrease relative to a peer hospital with a higher proportion of NAP1 circulating strains,” Katz and colleagues wrote.
NAP1 emerged in Canada during an outbreak in 2002, according to the researchers. In epidemic settings, NAP1 has been linked to higher rates of mortality and CDI recurrence, but its impact on disease severity in the postepidemic setting is less clear.
For their study, Katz and colleagues examined data on adult inpatients hospitalized with a health care-associated CDI from 2009 to 2015. The information was collected through the Canadian Nosocomial Infection Surveillance Program, a network of 64 acute-care hospitals.
Over the 7-year study period, 20,623 infections were reported. The national rate peaked in 2011, with 6.7 infections per 10,000 patient-days. By 2015, the prevalence of health care-associated CDI decreased to 4.3 per 10,000 patient-days, representing a 35.8% reduction.
Of the 2,690 isolates with microbiological data, the most commonly found CDI strain was NAP1 (37.6%), followed by NAP4 (14.2%) and NAP 11 (5.9%). The prevalence of NAP1 declined over time from 47% in 2009 to 28.5% in 2015. This correlated with an increase in NAP4 (8.7% to 18.5%) and NAP11 (1.1% to 9.2%) prevalence, as well as a decrease in moxifloxacin resistance (63.3% to 34.3%), which was found in 94.6% of NAP1 isolates. Researchers also observed an association between the proportion of NAP1 strains within facilities and infection rates. For every 10% increase in NAP1 among all C. difficile strains at each individual facility, there was a 3.3% (95% CI, 1.7-4.9) increase in health-care associated CDI.
In a multivariable analysis, patients infected with NAP1 had higher rates of CDI-related mortality than those with other CDI strains (OR = 1.91; 95% CI, 1.29-2.82). There was no significant link between strain type and all-cause mortality.
“Although the NAP1 strain was associated with attributable death in nonepidemic settings, the reduction in the proportion of NAP1 isolates has likely contributed to the improvement in local and national institutional rates of health care-associated [CDI],” the researchers concluded. “Infection prevention and control practices, antimicrobial stewardship and environmental cleaning should continue to be strengthened at the local level, as these areas positively affect institutional rates of health care-associated [CDI], regardless of circulating strain types.” – by Stephanie Viguers
Disclosures: Katz reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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