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Sahrmann JM, Olsen MA, Stwalley D, Yu H, Dubberke ER. Costs Attributable to Clostridioides difficile Infection Based on the Setting of Onset. Clin Infect Dis 2023; 76:809-815. [PMID: 36285546 PMCID: PMC10226732 DOI: 10.1093/cid/ciac841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/06/2022] [Accepted: 10/20/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although hospital-onset Clostridioides difficile infection (CDI) is associated with significant healthcare costs, the economic burden of CDI with onset in other facilities or the community has not been well studied. METHODS Incident CDI cases were identified using 2011-2017 Medicare fee-for-service data. Controls were randomly selected in a 4:1 ratio matching to the CDI case surveillance definition. Inverse probability of exposure weights were used to balance on measured confounders. One-, 3-, and 5-year cumulative costs attributable to CDI were computed using a 3-part estimator (parametric survival model and pair of 2-part models predicting costs separately in intervals where death did and did not occur). RESULTS A total of 60 492 CDI cases were frequency-matched to 241 968 controls. One-, 3-, and 5-year adjusted attributable costs were highest for hospital-onset CDI at $14 257, $18 953, and $21 792, respectively, compared with hospitalized controls and lowest for community-associated CDI compared with community controls at $1013, $3161, and $6454, respectively. Adjusted 1-, 3-, and 5-year costs attributable to community-onset healthcare facility-associated CDI were $8222, $13 066, and $16 329 and for other healthcare facility-onset CDI were $5345, $6764, and $7125, respectively. CONCLUSIONS Economic costs attributable to CDI in elderly persons were highest for hospital-onset and community-onset healthcare facility-associated CDI. Although lower, attributable costs due to CDI were significantly higher in cases with CDI onset in the community or other healthcare facility than for comparable persons without CDI. Additional strategies to prevent CDI in the elderly are needed to reduce morbidity and healthcare expenditures.
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Affiliation(s)
- John M Sahrmann
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Margaret A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dustin Stwalley
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Holly Yu
- Pfizer, Inc., Collegeville, Pennsylvania, USA
| | - Erik R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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Kim DY, Lee YM, Park KH, Kim YJ, Kang KC, Lee CK, Lee MS. Clostridium difficile infection after orthopedic surgery: Incidence, associated factors, and impact on outcome. Am J Infect Control 2022; 50:72-76. [PMID: 34437950 DOI: 10.1016/j.ajic.2021.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND To identify the incidence, associated factors, and impact of hospital-acquired Clostridium difficile infection (CDI) among patients who have undergone orthopedic surgery. METHODS We retrospectively reviewed the charts of all adults patients who underwent orthopedic surgery from January 2016 through December 2017 at a tertiary hospital. RESULTS Of 7,363 patients who underwent orthopedic surgical procedures, 52 (0.7%) developed hospital-acquired CDI. The independent factors associated with CDI were age ≥65 years (adjusted odds ratio [aOR], 3.4; P < .001), preoperative hospital stay ≥3 days (aOR, 3.7; P < .001), operating time ≥3 hours (aOR, 2.5; P < .005), and antibiotic use for infection treatment (aOR, 4.3; P < .001). After adjusting for the timing of CDI using a multistate model, the mean excess LOS attributable to CDI was 2.8 days (95% confidence interval [CI], 0.4-5.3). The impact of CDI on excess LOS was more evident among patients aged ≥65 years (4.4 days; 95% CI, 1.8-7.0) and those with any comorbidity (5.6 days; 95% CI, 3.0-8.1). CONCLUSIONS The overall incidence of CDI after orthopedic surgery was 0.7%. The occurrence of CDI after orthopedic surgery contributes to increased LOS. The greatest impact of CDI on LOS occurs among elderly patients and patients with comorbidities.
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Madden GR, Smith DC, Poulter MD, Sifri CD. Propensity-Matched Cost of Clostridioides difficile Infection Overdiagnosis. Open Forum Infect Dis 2020; 8:ofaa630. [PMID: 33575420 PMCID: PMC7863872 DOI: 10.1093/ofid/ofaa630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022] Open
Abstract
Background Clostridioides difficile is the leading health care–associated pathogen, but clinicians lack a test that can reliably differentiate colonization from infection. Health care costs attributed to C. difficile are substantial, but the economic burden associated with C. difficile false positives is poorly understood. Methods A propensity score matching model for cost per hospitalization was developed to estimate the costs of both true infection and false positives. Predictors of C. difficile positivity used to estimate the propensity score were age, Charlson comorbidity index, white cell count, and creatinine. We used polymerase chain reaction (PCR) cycle threshold to identify and compare 3 groups: (1) true infection, (2) C. difficile colonization, and (3) C. difficile negative. Results A positive test was associated with $3018 higher unadjusted hospital cost. Among the 3 comparisons made with propensity-matched negative controls (all positives [+$179; P = .934], true positives [–$1892; P = .100], and colonized positives), only colonization was associated with significantly increased (+$3418; P = .012) cost. Differences in lengths of stay (all positives 0 days, P = .126; true 0 days, P = .919; colonized 1 day, P = .019) appeared to underly cost differences. Conclusions In the first C. difficile cost analysis to utilize PCR cycle threshold to differentiate colonization, we found high propensity-matched hospital costs associated with colonized but not true positives. This unexpected finding may be due to misdiagnosis of non–C. difficile diarrhea or unadjusted factors associated with colonization.
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Affiliation(s)
- Gregory R Madden
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - David C Smith
- University of Virginia McIntire School of Commerce, Charlottesville, Virginia, USA
| | - Melinda D Poulter
- Clinical Microbiology Laboratory, Department of Pathology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Costi D Sifri
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.,Office of Hospital Epidemiology/Infection Prevention & Control, UVA Health, Charlottesville, Virginia, USA
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4
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Madden GR, Enfield KB, Sifri CD. Patient Outcomes With Prevented vs Negative Clostridioides difficile Tests Using a Computerized Clinical Decision Support Tool. Open Forum Infect Dis 2020; 7:ofaa094. [PMID: 32328506 PMCID: PMC7166115 DOI: 10.1093/ofid/ofaa094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background Overtesting and overdiagnosis of Clostridioides difficile infection are suspected to be common. Reducing inappropriate testing through interventions designed to promote evidence-based diagnostic testing (ie, diagnostic stewardship) may improve C. difficile test utilization. However, the safety of these interventions is not well understood despite the potential risk for missed or delayed diagnoses. Methods This retrospective case-control study examined the outcomes of patients admitted to the University of Virginia Medical Center following introduction of a computerized clinical decision support tool without hard-stops designed to reduce inappropriate tests. Outcomes were compared between patients with a prevented C. difficile nucleic acid amplification test and those with a negative result. Chart reviews were performed for patients with a subsequent positive within 7 days, as well as those patients who received C. difficile-active antibiotics after implementation of the computerized clinical decision support tool. Results Multivariate analysis of 637 cases (490 negative, 147 prevented) showed that a prevented test was not significantly associated with the primary composite outcome (inpatient mortality or intensive care unit transfer) compared with a negative test (adjusted odds ratio, 0.912; P = .747). Fifty-four of 147 (37%) prevented tests were followed by a completed test within 7 days; 11 of these results were positive, resulting in a potential delay in diagnosis. Individual case reviews found that either clinical changes warranted the delay in testing or no adverse events occurred attributable to C. difficile infection. C. difficile treatment without a positive test was not identified. Conclusions Diagnostic stewardship of C. difficile testing using computerized clinical decision support may be both safe and effective for reducing inappropriate inpatient testing.
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Affiliation(s)
- Gregory R Madden
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Kyle B Enfield
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Costi D Sifri
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.,Office of Hospital Epidemiology/Infection Prevention & Control, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Kimura T, Stanhope S, Sugitani T. Excess length of hospital stay, mortality and cost attributable to Clostridioides ( Clostridium) difficile infection and recurrence: a nationwide analysis in Japan. Epidemiol Infect 2020; 148:e65. [PMID: 32115019 PMCID: PMC7118723 DOI: 10.1017/s0950268820000606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 12/19/2019] [Accepted: 02/26/2020] [Indexed: 12/19/2022] Open
Abstract
Clostridioides (Clostridium) difficile infection (CDI) is the leading cause of infectious diarrhoea in hospitalised patients, representing a substantial economic burden driven mainly by increased length of hospital stay (LoS). Currently in Japan, limited evidence on CDI-associated excess LoS is available. We conducted a retrospective, matched-cohort study using a large, Japanese, hospital-based administrative database. CDI was defined as CDI treatment plus either CDI diagnosis or positive enzyme immunoassay result. Propensity score matching at the time of CDI or recurrent CDI (rCDI) onset was applied to adjust baseline confounding and immortal time bias. The analysis included 5 994 054 hospitalisation records during 2008-2017, of which 11 823 were identified as CDI and 1359 as rCDI. The median excess LoS attributable to CDI and rCDI was 3 days and 6.5 days, respectively. The excess mortality attributable to CDI was 6.9%; there was no excess mortality attributable to rCDI (-1.9%). The median difference in costs attributable to CDI and rCDI during the residual stay was JPY 130 296 (USD 1185) and JPY 81 054 (USD 737) per hospitalisation, respectively. By adjusting the biases, the burden of CDI in Japan was evaluated. The findings could support decision making and resource allocation for CDI management in Japanese hospitals.
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Rauseo AM, Olsen MA, Reske KA, Dubberke ER. Strategies to prevent adverse outcomes following Clostridioides difficile infection in the elderly. Expert Rev Anti Infect Ther 2020; 18:203-217. [PMID: 31976779 DOI: 10.1080/14787210.2020.1717950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Clostridioides difficile remains the most common cause of healthcare-associated infections in the US, and it disproportionately affects the elderly. Older patients are more susceptible and have a greater risk of adverse outcomes from C. difficile infection (CDI), despite advances in treatment and prevention.Areas covered: The epidemiology and pathogenesis of CDI, as well as risk factors in the aging host, will be reviewed. The importance of antimicrobial stewardship and infection prevention in order to avoid acquisition and transmission will be discussed, as well as strategies to prevent adverse outcomes and recurrent CDI, through optimization of CDI treatment s,election.Expert opinion: Appropriate CDI-prevention strategies to avoid adverse outcomes in this susceptible population involve antimicrobial stewardship and methods to prevent C. difficile transmission in healthcare settings. Management strategies to prevent adverse outcomes include initiation of supportive therapy and proper selection of CDI specific treatments. Many patients may also benefit from adjunctive therapies or additional procedures.
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Affiliation(s)
- Adriana M Rauseo
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA
| | - Margaret A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA
| | - Kimberly A Reske
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA
| | - Erik R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA
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Marra AR, Perencevich EN, Nelson RE, Samore M, Khader K, Chiang HY, Chorazy ML, Herwaldt LA, Diekema DJ, Kuxhausen MF, Blevins A, Ward MA, McDanel JS, Nair R, Balkenende E, Schweizer ML. Incidence and Outcomes Associated With Clostridium difficile Infections: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e1917597. [PMID: 31913488 PMCID: PMC6991241 DOI: 10.1001/jamanetworkopen.2019.17597] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions. OBJECTIVE To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis. DATA SOURCES MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS. STUDY SELECTION Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria. DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I2 value. Data analysis was performed in February 2019. MAIN OUTCOMES AND MEASURES Incidence of CDI and CDI-associated hospital LOS in the United States. RESULTS When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days). CONCLUSIONS AND RELEVANCE Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.
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Affiliation(s)
- Alexandre R. Marra
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Eli N. Perencevich
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Richard E. Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Matthew Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Karim Khader
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital, Taichung City, Taiwan
| | - Margaret L. Chorazy
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Loreen A. Herwaldt
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Daniel J. Diekema
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | | | - Amy Blevins
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis
| | - Melissa A. Ward
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Jennifer S. McDanel
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Rajeshwari Nair
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
| | - Erin Balkenende
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Marin L. Schweizer
- Carver College of Medicine, Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa
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Zhou Q, Fan L, Lai X, Tan L, Zhang X. Estimating extra length of stay and risk factors of mortality attributable to healthcare-associated infection at a Chinese university hospital: a multi-state model. BMC Infect Dis 2019; 19:975. [PMID: 31747887 PMCID: PMC6864951 DOI: 10.1186/s12879-019-4474-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 09/13/2019] [Indexed: 11/23/2022] Open
Abstract
Background The current evidence of extra length of stay (LOS) attributable to healthcare-associated infection (HCAI) scarcely takes time-dependent bias into consideration. Plus, limited evidences were from developing countries. We aim to estimate the extra LOS and risk factors of mortality attributable to HCAI for inpatients. Methods Multi-state model (MSM) was adopted to estimate the extra LOS attributable to HCAI of each type and subgroup. COX regression model was used to examine the risk of mortality. Results A total of 51,691 inpatients were included and 1709 (3.31%) among them developed HCAI. Lower respiratory tract infection and Acinetobacter baumannii were the most prevalent HCAI and causative pathogen in surveyed institute. Generally, the expected extra LOS attributable to HCAI was 2.56 days (95% confidence interval: 2.54–2.61). Patients below 65 had extra LOS attributable to HCAI longer about 2 days than those above. The extra LOS attributable to HCAI of male patients was 1.33 days longer than female. Meanwhile, age above 65 years old and HCAI were the risk factors of mortality for inpatients. Conclusions HCAI contributes to an increase in extra LOS of inpatients in China. The effect of HCAI on extra LOS is different among subgroups, with the age below 65, male and medicine department more sensitive.
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Affiliation(s)
- Qian Zhou
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, People's Republic of China
| | - Lili Fan
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, People's Republic of China
| | - Xiaoquan Lai
- Department of Nosocomial Infection, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, People's Republic of China
| | - Li Tan
- Department of Nosocomial Infection, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, People's Republic of China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, People's Republic of China.
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O'Hagan JJ, McDonald LC. The Challenges of Tracking Clostridium difficile to Its Source in Hospitalized Patients. Clin Infect Dis 2019; 68:210-212. [PMID: 29846537 DOI: 10.1093/cid/ciy461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
- Justin J O'Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Heister T, Wolkewitz M, Hehn P, Wolff J, Dettenkofer M, Grundmann H, Kaier K. Costs of hospital-acquired Clostridium difficile infections: an analysis on the effect of time-dependent exposures using routine and surveillance data. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2019; 17:16. [PMID: 31388335 PMCID: PMC6670202 DOI: 10.1186/s12962-019-0184-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
Background Hospital-acquired infections have not only gained increasing attention clinically, but also methodologically, as a time-varying exposure. While methods to appropriately estimate extra length of stay (LOS) have been established and are increasingly used in the literature, proper estimation of cost figures has lagged behind. Methods Analysing the additional costs and reimbursements of Clostridium difficile-infections (CDI), we use a within-main-diagnosis-time-to-exposure stratification approach to incorporate time-varying exposures in a regression model, while at the same time accounting for cost clustering within diagnosis groups. Results We find that CDI is associated with €9000 of extra costs, €7800 of higher reimbursements, and 6.4 days extra length of stay. Using a conventional method, which suffers from time-dependent bias, we derive estimates more than three times as high (€23,000, €8000, 21 days respectively). We discuss our method in the context of recent methodological advances in the estimation of the costs of hospital-acquired infections. Conclusions CDI is associated with sizeable in-hospital costs. Neglecting the methodological particularities of hospital-acquired infections can however substantially bias results. As the data needed for an appropriate analysis are collected routinely in most hospitals, we recommend our approach as a feasible way for estimating the economic impact of time-varying adverse events during hospital stay.
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Affiliation(s)
- Thomas Heister
- 1Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
| | - Martin Wolkewitz
- 1Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
| | - Philip Hehn
- 1Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
| | - Jan Wolff
- 2Department of Psychiatry and Psychotherapy, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Markus Dettenkofer
- Institute for Hospital Hygiene and Infection Prevention, Gesundheitsverbund Landkreis Konstanz, Radolfzell, Germany
| | - Hajo Grundmann
- 4Division of Infection Control and Hospital Epidemiology, University Medical Center Freiburg, Freiburg, Germany
| | - Klaus Kaier
- 1Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Stefan-Meier-Str. 26, 79104 Freiburg, Germany
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Falcone M, Tiseo G, Venditti M, Menichetti F. Updates in the epidemiology and management of candidemia and Clostridioides difficile coinfection. Expert Rev Anti Infect Ther 2019; 17:375-382. [PMID: 30982376 DOI: 10.1080/14787210.2019.1608183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: In recent years, more and more studies have focused on the association between candidemia and Clostridioides difficile infection (CDI), highlighting the risk of subsequent candidemia in patients with CDI. However, a more recent model focuses on the Candida-Clostridioides difficile coinfection as a clinical entity in which candidemia could occur before or after the CDI episode. Areas covered: In this review we analyzed the physiopathological mechanisms underlying the Candida-Clostridioides difficile coinfection, both in case of candidemia preceding and following the CDI. We highlighted that gut alterations occurring during a CDI play a crucial role in the risk of subsequent candidemia. Moreover, we identified areas of interest about the management of Candida-Clostridioides difficile coinfection and proposed answers to relevant clinical questions. Expert opinion: The evaluation of risk factors for candidemia in patients with CDI and the rational antibiotic use in patients with candidemia remain the most efficacious and cost-free instruments to optimally manage the Candida-Clostridioides difficile coinfection. However, further studies are required to cover some unmet needs, such as the development of rapid diagnostic methods of candidemia and the use of new available drugs with minimal effect on the microbiome biodiversity in patients with CDI at high risk of fungemia.
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Affiliation(s)
- Marco Falcone
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Giusy Tiseo
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Mario Venditti
- b Department of Public Health and Infectious Diseases , 'Sapienza' University of Rome , Rome , Italy
| | - Francesco Menichetti
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
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Estimating the Attributable Disease Burden and Effects of Interhospital Patient Sharing on Clostridium difficile Infections. Infect Control Hosp Epidemiol 2019; 40:656-661. [DOI: 10.1017/ice.2019.73] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AbstractObjective:To estimate the burden of Clostridium difficile infections (CDIs) due to interfacility patient sharing at regional and hospital levels.Design:Retrospective observational study.Methods:We used data from the Healthcare Cost and Utilization Project California State Inpatient Database (2005–2011) to identify 26,878,498 admissions and 532,925 patient transfers. We constructed a weighted, directed network among the hospitals by defining an edge between 2 hospitals to be the monthly average number of patients discharged from one hospital and admitted to another on the same day. We then used a network autocorrelation model to study the effect of the patient sharing network on the monthly average number of CDI cases per hospital, and we estimated the proportion of CDI cases attributable to the network.Results:We found that 13% (95% confidence interval [CI], 7.6%–18%) of CDI cases were due to diffusion through the patient-sharing network. The network autocorrelation parameter was estimated at 5.0 (95% CI, 3.0–6.9). An increase in the number of patients transferred into and/or an increased CDI rate at the hospitals from which those patients originated led to an increase in the number of CDIs in the receiving hospital.Conclusions:A minority but substantial burden of CDI infections are attributable to hospital transfers. A hospital’s infection control may thus be nontrivially influenced by its neighboring hospitals. This work adds to the growing body of evidence that intervention strategies designed to minimize HAIs should be done at the regional rather than local level.
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Fukuda H, Yano T, Shimono N. Inpatient Expenditures Attributable to Hospital-Onset Clostridium difficile Infection: A Nationwide Case-Control Study in Japan. PHARMACOECONOMICS 2018; 36:1367-1376. [PMID: 30022364 DOI: 10.1007/s40273-018-0692-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Hospital-onset Clostridium difficile infections (CDIs) have a considerable clinical and economic impact on patients and payers. Quantifying the economic impact of CDIs can guide treatment strategies. However, previous studies have generally focused on acute care hospitals, and few have included cost estimates from non-acute care hospitals such as long-term care facilities. AIM This study aimed to quantify the hospital-onset CDI-attributable inpatient expenditures and length-of-stay durations in all healthcare institutions that provide inpatient care (including acute and non-acute care) in Japan. METHODS Using national-level insurance claims data, we analyzed patients who had been hospitalized between April 2010 and December 2016. CDI cases were identified and matched with non-CDI controls using hospitalization year, treating hospital, age, sex, surgical procedure, comorbidities, and main diagnoses. Through multivariable regression analyses, we estimated the CDI-attributable inpatient expenditures (2016 US dollars) and length-of-stay durations (days) while adjusting for variations in factors such as patient characteristics, comorbidities, surgery, prescribed antibiotic, geographic region, and hospitalization year. We also analyzed the CDI-attributable inpatient expenditures and length-of-stay durations according to hospital type (acute care and rehabilitation/long-term care). RESULTS The analysis was conducted using 3768 matched pairs. Overall, CDI-attributable inpatient expenditures and length-of-stay durations were US$3213 and 11.96 days, respectively. Rehabilitation/long-term care hospitals had substantially higher inpatient expenditures and longer hospitalizations than acute care hospitals. CONCLUSION This study quantified the hospital-onset CDI-attributable inpatient expenditures and hospitalizations in both acute and non-acute care hospitals. The inclusion of non-acute care hospitals provides a more accurate representation of the economic burden of CDIs.
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Affiliation(s)
- Haruhisa Fukuda
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan.
| | - Takahisa Yano
- Center for the Study of Global Infection, Kyushu University Hospital, Fukuoka, Japan
| | - Nobuyuki Shimono
- Center for the Study of Global Infection, Kyushu University Hospital, Fukuoka, Japan
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Manoukian S, Stewart S, Dancer S, Graves N, Mason H, McFarland A, Robertson C, Reilly J. Estimating excess length of stay due to healthcare-associated infections: a systematic review and meta-analysis of statistical methodology. J Hosp Infect 2018; 100:222-235. [PMID: 29902486 DOI: 10.1016/j.jhin.2018.06.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/05/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Healthcare-associated infection (HCAI) affects millions of patients worldwide. HCAI is associated with increased healthcare costs, owing primarily to increased hospital length of stay (LOS) but calculating these costs is complicated due to time-dependent bias. Accurate estimation of excess LOS due to HCAI is essential to ensure that we invest in cost-effective infection prevention and control (IPC) measures. AIM To identify and review the main statistical methods that have been employed to estimate differential LOS between patients with, and without, HCAI; to highlight and discuss potential biases of all statistical approaches. METHODS A systematic review from 1997 to April 2017 was conducted in PubMed, CINAHL, ProQuest and EconLit databases. Studies were quality-assessed using an adapted Newcastle-Ottawa Scale (NOS). Methods were categorized as time-fixed or time-varying, with the former exhibiting time-dependent bias. Two examples of meta-analysis were used to illustrate how estimates of excess LOS differ between different studies. FINDINGS Ninety-two studies with estimates on excess LOS were identified. The majority of articles employed time-fixed methods (75%). Studies using time-varying methods are of higher quality according to NOS. Studies using time-fixed methods overestimate additional LOS attributable to HCAI. Undertaking meta-analysis is challenging due to a variety of study designs and reporting styles. Study differences are further magnified by heterogeneous populations, case definitions, causative organisms, and susceptibilities. CONCLUSION Methodologies have evolved over the last 20 years but there is still a significant body of evidence reliant upon time-fixed methods. Robust estimates are required to inform investment in cost-effective IPC interventions.
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Affiliation(s)
- S Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK.
| | - S Stewart
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK
| | - S Dancer
- Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire, UK
| | - N Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - H Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK
| | - A McFarland
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK
| | - C Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - J Reilly
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK
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Mora Pinzon MC, Buie R, Liou JI, Shirley DK, Evans CT, Ramanathan S, Poggensee L, Safdar N. Outcomes of Community and Healthcare-onsetClostridium difficileInfections. Clin Infect Dis 2018; 68:1343-1350. [DOI: 10.1093/cid/ciy715] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/17/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
| | - Ronald Buie
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle
- William S. Middleton Memorial Veterans Affairs Hospital, Madison
| | - Jinn-ing Liou
- William S. Middleton Memorial Veterans Affairs Hospital, Madison
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Daniel K Shirley
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Department of Veterans Affairs, Edward Hines Jr Veterans Affairs Hospital, Chicago, Illinois
- Department of Preventive Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois
| | - Swetha Ramanathan
- Center of Innovation for Complex Chronic Healthcare, Department of Veterans Affairs, Edward Hines Jr Veterans Affairs Hospital, Chicago, Illinois
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare, Department of Veterans Affairs, Edward Hines Jr Veterans Affairs Hospital, Chicago, Illinois
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Affairs Hospital, Madison
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison
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Barker AK, Alagoz O, Safdar N. Interventions to Reduce the Incidence of Hospital-Onset Clostridium difficile Infection: An Agent-Based Modeling Approach to Evaluate Clinical Effectiveness in Adult Acute Care Hospitals. Clin Infect Dis 2018; 66:1192-1203. [PMID: 29112710 PMCID: PMC5888988 DOI: 10.1093/cid/cix962] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/31/2017] [Indexed: 12/18/2022] Open
Abstract
Background Despite intensified efforts to reduce hospital-onset Clostridium difficile infection (HO-CDI), its clinical and economic impacts continue to worsen. Many institutions have adopted bundled interventions that vary considerably in composition, strength of evidence, and effectiveness. Considerable gaps remain in our knowledge of intervention effectiveness and disease transmission, which hinders HO-CDI prevention. Methods We developed an agent-based model of C. difficile transmission in a 200-bed adult hospital using studies from the literature, supplemented with primary data collection. The model includes an environmental component and 4 distinct agent types: patients, visitors, nurses, and physicians. We used the model to evaluate the comparative clinical effectiveness of 9 single interventions and 8 multiple-intervention bundles at reducing HO-CDI and asymptomatic C. difficile colonization. Results Daily cleaning with sporicidal disinfectant and C. difficile screening at admission were the most effective single-intervention strategies, reducing HO-CDI by 68.9% and 35.7%, respectively (both P < .001). Combining these interventions into a 2-intervention bundle reduced HO-CDI by 82.3% and asymptomatic hospital-onset colonization by 90.6% (both, P < .001). Adding patient hand hygiene to healthcare worker hand hygiene reduced HO-CDI rates an additional 7.9%. Visitor hand hygiene and contact precaution interventions did not reduce HO-CDI, compared with baseline. Excluding those strategies, healthcare worker contact precautions were the least effective intervention at reducing hospital-onset colonization and infection. Conclusions Identifying and managing the vast hospital reservoir of asymptomatic C. difficile by screening and daily cleaning with sporicidal disinfectant are high-yield strategies. These findings provide much-needed data regarding which interventions to prioritize for optimal C. difficile control.
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Affiliation(s)
- Anna K Barker
- Department of Population Health Sciences, School of Medicine and Public Health, Madison, Wisconsin
| | - Oguzhan Alagoz
- Department of Population Health Sciences, School of Medicine and Public Health, Madison, Wisconsin
- Department of Industrial and Systems Engineering, College of Engineering, Madison, Wisconsin
| | - Nasia Safdar
- Division of Infectious Diseases, Department of Medicine, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, Wisconsin
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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Screening for Asymptomatic Clostridium difficile Among Bone Marrow Transplant Patients: A Mixed-Methods Study of Intervention Effectiveness and Feasibility. Infect Control Hosp Epidemiol 2018; 39:177-185. [PMID: 29366434 DOI: 10.1017/ice.2017.286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To identify facilitators and barriers to implementation of a Clostridium difficile screening intervention among bone marrow transplant (BMT) patients and to evaluate the clinical effectiveness of the intervention on the rate of hospital-onset C. difficile infection (HO-CDI). DESIGN Before-and-after trial SETTING A 505-bed tertiary-care medical center PARTICIPANTS All 5,357 patients admitted to the BMT and general medicine wards from January 2014 to February 2017 were included in the study. Interview participants included 3 physicians, 4 nurses, and 4 administrators. INTERVENTION All BMT patients were screened within 48 hours of admission. Colonized patients, as defined by a C. difficile-positive polymerase chain reaction (PCR) stool result, were placed under contact precautions for the duration of their hospital stay. METHODS Interview responses were coded according to the Systems Engineering Initiative for Patient Safety conceptual framework. We compared pre- and postintervention HO-CDI rates on BMT and general internal medicine units using time-series analysis. RESULTS Stakeholder engagement, at both the person and organizational level, facilitates standardization and optimization of intervention protocols. While the screening intervention was generally well received, tools and technology were sources of concern. The mean incidence of HO-CDI decreased on the BMT service postintervention (P<.0001). However, the effect of the change in the trend postintervention was not significantly different on BMT compared to the control wards (P=.93). CONCLUSIONS We report the first mixed-methods study to evaluate a C. difficile screening intervention among the BMT population. The positive nature by which the intervention was received by front-line clinical staff, laboratory staff, and administrators is promising for future implementation studies. Infect Control Hosp Epidemiol 2018;39:177-185.
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Pak TR, Chacko K, O’Donnell T, Huprikar S, van Bakel H, Kasarskis A, Scott ER. Estimating Local Costs Associated With Clostridium difficile Infection Using Machine Learning and Electronic Medical Records. Infect Control Hosp Epidemiol 2017; 38:1478-1486. [PMID: 29103378 PMCID: PMC5923033 DOI: 10.1017/ice.2017.214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reported per-patient costs of Clostridium difficile infection (CDI) vary by 2 orders of magnitude among different hospitals, implying that infection control officers need precise, local analyses to guide rational decision making between interventions. OBJECTIVE We sought to comprehensively estimate changes in length of stay (LOS) attributable to CDI at a single urban tertiary-care facility using only data automatically extractable from the electronic medical record (EMR). METHODS We performed a retrospective cohort study of 171,938 visits spanning a 7-year period. In total, 23,968 variables were extracted from EMR data recorded within 24 hours of admission to train elastic-net regularized logistic regression models for propensity score matching. To address time-dependent bias (reverse causation), we separately stratified comparisons by time of infection, and we fit multistate models. RESULTS The estimated difference in median LOS for propensity-matched cohorts varied from 3.1 days (95% CI, 2.2-3.9) to 10.1 days (95% CI, 7.3-12.2) depending on the case definition; however, dependency of the estimate on time to infection was observed. Stratification by time to first positive toxin assay, excluding probable community-acquired infections, showed a minimum excess LOS of 3.1 days (95% CI, 1.7-4.4). Under the same case definition, the multistate model averaged an excess LOS of 3.3 days (95% CI, 2.6-4.0). CONCLUSIONS In this study, 2 independent time-to-infection adjusted methods converged on similar excess LOS estimates. Changes in LOS can be extrapolated to marginal dollar costs by multiplying by average costs of an inpatient day. Infection control officers can leverage automatically extractable EMR data to estimate costs of CDI at their own institutions. Infect Control Hosp Epidemiol. 2017;38:1478-1486.
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Affiliation(s)
- Theodore R. Pak
- Icahn Institute and Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kieran Chacko
- Icahn Institute and Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Timothy O’Donnell
- Icahn Institute and Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shirish Huprikar
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Harm van Bakel
- Icahn Institute and Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew Kasarskis
- Icahn Institute and Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Erick R. Scott
- Icahn Institute and Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
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Dirweesh A, Alvarez C, Khan M, Ambreen B, Yelisetti R, Hamiz SF, Zia S, Tahir M, DeBari VA, Christmas D, Wallach S. Lack of Association Between the Clinical Outcome of Clostridium difficile Infection and Current Steroids Use. Gastroenterology Res 2017; 10:116-119. [PMID: 28496532 PMCID: PMC5412544 DOI: 10.14740/gr822w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2017] [Indexed: 02/04/2023] Open
Abstract
Background The purpose of this study was to compare the outcome of Clostridium difficile infection (CDI) in patients on systemic steroids for various indications to patients not on steroids in term of disease severity, and associated morbidity and mortality. Methods We retrospectively reviewed records of all patients with CDI at our hospital from January 2011 to December 2016. Patients were evaluated for baseline characteristics, comorbidities, medications, disease severity, disease-related length of stay (LOS) from the diagnosis of CDI to discharge, need for surgical intervention, and disease-related mortality. Based on systemic steroids use, patients who were using steroids for different indications constituted the study population, and those with no steroids use were clustered as a control group. Results Of the 258 patients included, males were 127 (49%). Severe and severe-complicated CDI developed in 21/63 (33.3%) and 1/63 (1.6%) of patients on steroids (average daily dose of 20 mg), and in 73/195 (37.4%) and 5/195 (2.6%) of patients with no steroids use (P = 0.56 and P = 0.66, respectively). Surgical intervention was not required in the steroids group and 5/195 (2.7%) of patients not on steroids underwent bowel surgeries (P = 0.38). Mean LOS (days) was 11.6 ± 1.5 in the steroids group and 10.4 ± 0.7 in the no-steroids group (P = 0.4). CDI-related mortality occurred in 9/63(14.3%) of patients on steroids, and in 15/195 (7.7%) of patients not on steroids (P = 0.12; odds ratio (OR): 2; 95% confidence interval (CI): 0.8 - 4.8). Conclusion There was no significant difference in the severity of CDI, need for surgical interventions, disease-related LOS and mortality in systemic steroids users compared to patients not on steroids.
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Affiliation(s)
- Ahmed Dirweesh
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Chikezie Alvarez
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Muhammad Khan
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Bushra Ambreen
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Rishitha Yelisetti
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Shaikh Fawwad Hamiz
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Sana Zia
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Muhammad Tahir
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Vincent A DeBari
- Department of Internal Medicine, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, USA
| | - Donald Christmas
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
| | - Sara Wallach
- Department of Internal Medicine, Seton Hall University, Saint Francis Medical Center, Trenton, NJ, USA
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van Beurden YH, Dekkers OM, Bomers MK, Kaiser AM, van Houdt R, Knetsch CW, Girbes ARJ, Mulder CJJ, Vandenbroucke-Grauls CMJE. An Outbreak of Clostridium difficile Ribotype 027 Associated with Length of Stay in the Intensive Care Unit and Use of Selective Decontamination of the Digestive Tract: A Case Control Study. PLoS One 2016; 11:e0160778. [PMID: 27533048 PMCID: PMC4988663 DOI: 10.1371/journal.pone.0160778] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/25/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND An outbreak of Clostridium difficile ribotype 027 infection (CDI) occurred at an university hospital, involving 19 departments. To determine what hospital-associated factors drove the outbreak of this particular strain we performed a case-control study. METHODS Cases (n = 79), diagnosed with CDI due to C. difficile ribotype 027 were matched for age and treating medical specialty to four control patients (n = 316). Patients diagnosed with CDI due to other ribotypes were included as a second control group. A random selection of C. difficile ribotype 027 strains (n = 10) was genotyped by Whole Genome Sequencing (WGS). FINDINGS WGS showed the outbreak was likely caused by a single strain of C. difficile (two or less single-nucleotide variants between isolates). Ninety-five percent of cases had used antibiotics, compared to 56% of controls. Previous admission to the intensive care unit (ICU) (OR: 2.4, 95% CI 1.0-5.6), longer length of stay (LOS), and recent hospital admission were associated with CDI ribotype 027. Cases were less likely to have been admitted to a ward with a known isolated CDI patient (OR: 0.2, 95% CI 0.1-0.6). Analysis of patients who stayed at the ICU (35 cases; 51 controls), indicated that the use of selective decontamination of the digestive tract (SDD) and a longer LOS in the ICU were associated with CDI risk. INTERPRETATION In this large outbreak, any antibiotic use, including SDD use, appeared as a prerequisite for acquisition of the outbreak strain. The role of use of SDD and prolonged stay on the ICU could not be disentangled, but both factors can play a biologically plausible role in C. difficile acquisition and infection.
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Affiliation(s)
- Yvette H. van Beurden
- Department of Medical Microbiology and Infection Control, VU University medical center, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, VU University medical center, Amsterdam, The Netherlands
- * E-mail:
| | - Olaf M. Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Marije K. Bomers
- Department of Internal Medicine, VU University medical center, Amsterdam, The Netherlands
| | - Annie M. Kaiser
- Department of Medical Microbiology and Infection Control, VU University medical center, Amsterdam, The Netherlands
| | - Robin van Houdt
- Department of Medical Microbiology and Infection Control, VU University medical center, Amsterdam, The Netherlands
| | - Cornelis W. Knetsch
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Armand R. J. Girbes
- Department of Intensive Care, VU University medical center, Amsterdam, The Netherlands
| | - Chris J. J. Mulder
- Department of Gastroenterology and Hepatology, VU University medical center, Amsterdam, The Netherlands
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Shah DN, Aitken SL, Barragan LF, Bozorgui S, Goddu S, Navarro ME, Xie Y, DuPont HL, Garey KW. Economic burden of primary compared with recurrent Clostridium difficile infection in hospitalized patients: a prospective cohort study. J Hosp Infect 2016; 93:286-9. [PMID: 27209056 DOI: 10.1016/j.jhin.2016.04.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/05/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Few studies have investigated the additional healthcare costs of recurrent C. difficile infection (CDI). AIM To quantify inpatient treatment costs for CDI and length of stay among hospitalized patients with primary CDI only, compared with CDI patients who experienced recurrent CDI. METHODS This was a prospective, observational cohort study of hospitalized adult patients with primary CDI followed for three months to assess for recurrent CDI episodes. Total and CDI-attributable hospital length of stay (LOS) and hospitalization costs were compared among patients who did or did not experience at least one recurrent CDI episode. FINDINGS In all, 540 hospitalized patients aged 62±17 years (42% males) with primary CDI were enrolled, of whom 95 patients (18%) experienced 101 recurrent CDI episodes. CDI-attributable median (interquartile range) LOS and costs (in US$) increased from 7 (4-13) days and $13,168 (7,525-24,456) for patients with primary CDI only versus 15 (8-25) days and $28,218 (15,050-47,030) for patients with recurrent CDI (P<0.0001, each). Total hospital median LOS and costs increased from 11 (6-22) days and $20,693 (11,287-41,386) for patients with primary CDI only versus 24 (11-48) days and $45,148 (20,693-82,772) for patients with recurrent CDI (P<0.0001, each). The median cost of pharmacological treatment while hospitalized was $60 (23-200) for patients with primary CDI only (N=445) and $140 (30-260) for patients with recurrent CDI (P=0.0013). CONCLUSION This study demonstrated that patients with CDI experience a significant healthcare economic burden attributed to CDI. Economic costs and healthcare burden increased significantly for patients with recurrent CDI.
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Affiliation(s)
- D N Shah
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - S L Aitken
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA; Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L F Barragan
- Internal Medicine Service, Baylor St Luke's Medical Center, Houston, TX, USA
| | - S Bozorgui
- Internal Medicine Service, Baylor St Luke's Medical Center, Houston, TX, USA
| | - S Goddu
- Internal Medicine Service, Baylor St Luke's Medical Center, Houston, TX, USA
| | - M E Navarro
- Internal Medicine Service, Baylor St Luke's Medical Center, Houston, TX, USA
| | - Y Xie
- Department of Outcomes Research, Merck & Co., Whitehouse Station, NJ, USA
| | - H L DuPont
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA; Internal Medicine Service, Baylor St Luke's Medical Center, Houston, TX, USA; Division of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA; Center for Infectious Diseases, University of Texas School of Public Health, Houston, TX, USA
| | - K W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA; Center for Infectious Diseases, University of Texas School of Public Health, Houston, TX, USA.
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