Outpatient C. difficile may be more common than thought, study results indicate
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Key takeaways:
- Hospitals in California detected a high rate of C. difficile among outpatients despite a low frequency of testing.
- The finding indicates that outpatient C. difficile infections may be underdiagnosed.
California hospitals detected a high incidence of Clostridioides difficile infection among outpatients treated for diarrhea despite a low rate of testing, suggesting that outpatient C. difficile may be underdiagnosed, researchers said.
C. difficile infection (CDI) “is one of the most common health care-associated infections and causes substantial burden to both health care systems and patients, particularly in the hospital setting,” Sara Y. Tartof, PhD, MPH, an epidemiologist for the Kaiser Permanente Southern California Department of Research & Evaluation, told Healio.
“However,” Tartof continued, “emerging data show that outpatient CDI is vastly underestimated. Recent CDC data demonstrate that the majority of CDI cases in older adults occurring in the community do not have subsequent hospitalization and are therefore considered outpatient CDI. Yet, the burden of outpatient CDI is not well described in literature, and we sought to bring some light to the situation.”
Tartof and colleagues conducted a retrospective cohort study of adults aged 18 years or older treated for diarrhea at Kaiser Permanente Southern California and Kaiser Permanente Northwest between Jan. 1, 2016, and Dec. 31, 2021.
Among the 777,533 cases they identified, 12.1% were tested for CDI, according to the study. Among those tested, 10.8% were positive for CDI.
They calculated the overall incidence of outpatient CDI to be 51 per 100,000 person-years (95% CI, 49.8-52.2), but noted a decrease in incidence from 58.2 (95% CI, 55.7-60.7) in 2016 to 45.7 (95% CI, 43.7-47.8) in 2021.
According to the researchers, “the low frequency of C. difficile testing among patients presenting with diarrhea indicates that outpatient CDI may be underdiagnosed and that the incidence of outpatient CDI may be higher than appreciated.”
In terms of health care utilization after diagnosis, the study showed that approximately 44% of patients received an antibiotic 30 days before the date of their diagnosis of diarrhea and 6.7% had a CDI-associated hospitalization within 12 months. The researchers noted that although the data did not show high health care utilization, they could not directly measure illness severity or impact on quality of life.
“The high incidence of outpatient CDI may contribute to transmission within households or other environments or may predispose high-risk patients with comorbidities to subsequent CDI infections in the event of an immunocompromising event or medication,” Tartof said. “Increased CDI testing among patients with [medically attended diarrhea] may be warranted in the outpatient setting, particularly for patients with known CDI risk factors.”
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