C. difficile infections fell during pandemic, but patients had higher mortality, costs
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Although the prevalence of Clostridioides difficile infection in the U.S. continued its long-term downward trend during the COVID-19 pandemic, patients who were infected saw high treatment costs and increased mortality, a study found.
The researchers found that patients diagnosed with C. difficile infection (CDI) during the pandemic had more severe illness, possibly because of changes in health care delivery — namely, that these were the only patients who would have been admitted.
“It is possible that patients who developed CDI in the outpatient setting may not have received as timely access to care during the pandemic. This could have been a contributing factor to poorer health outcomes we noted in our study,” lead author Kelly Reveles, PharmD, PhD, told Healio.
Reveles and colleagues conducted a retrospective cohort study of 25,992 CDI encounters representing 22,130 patients in the Premier Healthcare Database who had lab-confirmed CDIs between April 2019 through March 2020 — the pre-COVID-19 period — and April 2020 through March 2021.
“The continued decline in CDI prevalence during the pandemic may be due to several factors,” including better adherence to infection control practices in hospitals and new practices in outpatient settings, the researchers wrote in the study, published in Open Forum Infectious Diseases.
Additionally, hospitalizations for a variety of conditions decreased early in the pandemic. Many people avoided health care encounters during the pandemic, even when they had severe symptoms; and it is likely, as previous studies have found, that there were declines in testing because of symptom overlap between CDI and COVID-19.
According to Karuna Vendrik, MD, a PhD student at Leiden University Medical Center, during a study of the same timeframe in the Netherlands, she and her colleagues saw CDI diagnoses decline — with similar theories for the declines.
“It could be that there was less focus on other infectious diseases than COVID-19 during the first wave, but we do not know this for sure,” Vendrik, who was not involved in the current study, told Healio, adding that the decrease was mainly observed right after the first wave.
Researchers in the U.S. study found that overall CDI prevalence dropped to 8.9 cases per 10,000 patient encounters during the COVID-19 period, down from 12.2 cases per 10,000 patient encounters in the pre-COVID-19 period. Overall CDI prevalence for all encounters also decreased over the entire study period to 6.7 per 10,000 encounters in March 2021 from 13.3 per 10,000 encounters in April 2019.
Although cases decreased, patient costs went up by an average of $2,000 from the pre-COVID-19 period to the COVID-19 period. The researchers reported that this was driven primarily by inpatient treatment costs. Among inpatient encounters, deaths also increased between the two time periods, increasing to 7.4% in the COVID-19 period from 5.5% in the pre-COVID-19 period.
Reveles said it would be difficult to extrapolate how many cases of CDI were missed during the pandemic period “due to overlap in gastrointestinal symptoms commonly seen with COVID-19. Further studies are needed to define the impact of COVID-19 on CDI diagnostics and true infection rates.”
Most of the efforts to bring down CDI rates continued from the pre-COVID-19 period, she said, which could have also brought down the number of cases. Those that were missed were likely missed because testing was not done — but fewer hospitalized patients also could be the difference.
Improved hygiene and cleaning efforts at hospitals because of COVID-19 are potential explanations, Vendrik said, as are the combinations of less focus on CDI, fewer patients in hospitals, more protective clothing, and social distancing.
“Health care exposure is a major risk factor for CDI. Thus, lower hospitalization rates may result in fewer CDI cases,” Reveles said.
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