Category Archives: Community Acquired CDI

Study Finds C. difficile (CDI) Has the Potential Role of Transmission In Home Environment

 

 

 

 

Findings from a study by researchers from the University of Iowa highlights the potential role of the home environment in Clostridioides difficile transmission.

Using data from a commercial insurance claims database, the researchers found that the incidence of C difficile infection (CDI) among individuals living with a family member who had CDI was more than 12 times greater than the incidence in those without prior family exposure. The incidence rate was even higher in certain groups less likely to have other risk-increasing exposures.

The results of the study appeared Jun 26 in JAMA Open Network.

While the level of absolute CDI risk attributable to the household transmission was extremely low, the authors of the study say the findings may have practical implications for preventing the spread of CDI in households.

CDI can be spread in the community

C. difficile infection (CDI)  is a common, typically hospital-acquired infection that is mainly associated with antibiotic use and healthcare settings. While antibiotics create the conditions that allow for C difficile to flourish in the gut and cause infection, spores shed by infected patients (through fecal matter) and can be spread by healthcare workers and are frequently found on *bed rails, in the patient bathrooms, and other parts of the hospital environment.

(*High touch areas can be easily contaminated with Clostridioides difficile (C. difficile, C. diff.) spores) cdf note.

Those spores are often difficult to eliminate because they are resistant to many cleaning agents.

In 2017, according to the most recent data from the Centers for Disease Control and Prevention, there were an estimated 223,900 CDI cases in hospitalized patients.

But not all CDI cases start in hospitals. Some studies have found that CDI can be transmitted outside of healthcare settings, with persistent contamination of the household environment occurring in patients with documented infection. Others have found household pets colonized with the bacterium.

To better understand the potential role of household C difficile transmission, the University of Iowa researchers used a large population-based, commercial insurance claims data set to examine whether family members of CDI patients had a greater risk of acquiring the infection. Limiting the analysis to households with two or more family member enrolled in the same insurance plan for an entire month, they grouped individuals into four categories based on CDI status and family exposure to CDI: (1) CDI and prior family exposure, (2) no CDI and prior family exposure, (3) CDI and no family exposure, and (4) no CDI and no family exposure.

The primary outcome of the case-control study was the incidence of CDI in a given monthly enrollment stratum. Aside from exposure to CDI diagnosed in a family member, other CDI exposure risks were considered, including prior hospitalization, age, and antibiotic use. The researchers also conducted a separate analysis for CDI diagnosed in hospital or outpatient settings.

Higher risk from family exposure

Analysis of data covering 2001 through 2017 found that 224,818 CDI cases, representing 194,424 enrollees, occurred in families with at least two enrollees. Of these, 1,074 CDI cases (0.48%) occurred following a diagnosis in a separate family member, representing possible transmission. In general, the index cases of CDI tended to occur in older enrollees (ages 45 to 64 years), while the CDI cases that represented potential transmission events occurred in children.

A comparison of the incidence rate ratio (IRR) between individuals with and without family exposure showed that prior family exposure was significantly associated with an increased incidence of CDI (IRR, 12.47; 95% confidence interval [CI], 8.86 to 16.97) even after controlling for other risk factors. This was the second-highest IRR behind hospital exposure (IRR, 16.18; 95% CI, 15.31 to 17.10).

Increased CDI incidence was also associated with age (IRR, 9.90; 95% CI, 8.93 to 10.98 for people over age 65 compared with those aged 0 to 17) and antibiotic use (IRR, 7.78; 95% CI, 7.33 to 8.25 for people on high-CDI-risk antibiotics compared with no antibiotics).

When the researchers looked at subgroups of CDI cases less likely to be attributed to hospital exposure, they found that the IRR associated with family exposure was even higher—16.00 (95% CI, 11.72 to 21.22) for community-onset CDI and 21.74 (95% CI, 15.12 to 30.01) for community-onset CDI without prior hospitalization.

“For individuals with family exposure, the risk for being diagnosed with CDI remained consistent after controlling for CDI risk factors and different model specifications,” the authors wrote. “Together, these results suggest that individuals with family exposure may be at greater risk for acquiring CDI than those without exposure and highlight the importance of the shared environment in the transmission and acquisition of C difficile.”

The authors note that because they were not able to conduct whole-genome sequencing, they cannot confirm whether CDI cases within families represent identical strains. They also said the study is limited by the reliance on insurance claims data, which do not provide all the details necessary to determine attributable risk.

Despite the low absolute risk of acquiring CDI from a family member, the authors suggested that cleaning shared bathrooms with effective cleaning agents could be a practical way to minimize transmission risk.

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https://www.cidrap.umn.edu/news-perspective/2020/06/study-suggests-household-exposure-may-increase-c-difficile-risk

Community-acquired C. diff. Infection (CA-CDI)

How is Clostridioides difficile epidemiology changing?

 

What risk factors are associated with community-acquired C. diff (CA-CDI)?

How has molecular epidemiology improved our understanding of Cdiff transmission?

What are the potential novel sources of Cdiff?

Investigators with Duke University Medical Center certainly asked the right questions in “Novel and Emerging Sources of Clostridioides difficile Infection,” a new study published December 19 in PLOS Pathogens.

The global answer is that infection preventionists and other infection control professionals will have their work cut out for them in the coming year. They’ll have to contend with diversity among C. diff isolates, mounting evidence that it’s often transmitted outside the hospital, and that those multiple sources of infection will put current infection control processes to the test. Coming up with the best approach will take lots of exposure-related data, coupled with whole-genome sequencing.

“With the additional issues of widespread outpatient healthcare contact, asymptomatic carriage, and long-term environmental persistence of spores, even the basic distinction between community- versus healthcare-associated CDI may become less relevant with time,” the study states.

Mathematical modeling studies suggest reducing transmission would require that patients with C. diff be placed in single rooms and the healthcare workers who care for them wear gowns and gloves. Clinical data supporting this method are missing, however. “Molecular epidemiologic studies attribute a relatively small minority of transmission events to carriers,” the study states.

It’s more of a challenge to investigate CA-CDI than healthcare-associated infections (HAIs). There aren’t even that many population-based studies on CDI incidence, say, investigators.

Which population is most at risk?

And how does the healthcare system go about tracking it?

These questions have not been answered and don’t look to be answered anytime soon.

“One of the major issues with defining populations at risk for CA-CDI is a lack of centralized testing or surveillance,” the study states. “Because patients are able to present to urgent care, primary care offices, emergency rooms, and hospitals, often all belonging to different healthcare networks, it is extremely difficult to determine how many cases are occurring within a particular community.”

The fact that most C. diff interventions occur within the hospital also limits what can be done about CA-CDI. It’s also unclear just how the infection travels: from the community into the hospital, the other way around, or some combination of both?

Also, “even though healthcare contact is frequently associated with CA-CDI, it remains unclear if this reflects patients who are actually at elevated risk because of multiple chronic health problems or if contact with healthcare is truly what is driving the risk.”

Nursing homes and long-term care facilities seem to be breeding grounds for C. diff and may be a major source of C. diff infection in hospitals because many of the residents in those latter facilities often wind up in the hospital.

“With the additional issues of widespread outpatient healthcare contact, asymptomatic carriage, and long-term environmental persistence of spores, even the basic distinction between community- versus healthcare-associated CDI may become less relevant with time.

Given the challenges posed by current evidence of interspecies transmission and environmental reservoirs of Cdifficile, future research in C. difficile prevention will require an integrative multidisciplinary approach, as exemplified by the OneHealth concept.”

To view this article in its entirety, please click on the following link to be redirected.  Thank You.

https://www.infectioncontroltoday.com/hai-types/c-diff-conundrum-sources-harder-pin-down-making-control-difficult