Attributable costs and length of stay of hospital-acquired Clostridioides difficile: A population-based matched cohort study in Alberta, Canada

Demographic Characteristics and Economic Burden of Clostridioides difficile Infection in Korea: A Nationwide Population-Based Study after Propensity Score Matching

Clostridioides difficile infection (CDI) poses a considerable threat to global public health. However, there have been insufficient propensity score-matched data on its demographic characteristics and economic burden. Using nationwide claims data, we assessed longitudinal changes in the demographic characteristics and economic burden of CDI between 2011 and 2019 after propensity score matching. We performed a regression analysis to compare the differences in the length of hospital stay and medical costs between patients with CDI and controls (gastroenteritis and colitis). The CDI hospitalization rate increased 2.9-fold between 2011 and 2019. The CDI group had higher comorbidity index scores and was more frequently diagnosed at tertiary hospitals and in the Seoul region than the control group (all p < 0.001). The annual incidence rate of CDI/10,000 persons significantly increased in both sexes and all age groups. The length of hospital stay and medical costs were 3.3-fold and 5.0-fold greater, respectively, in the CDI than in the control group (both p < 0.001). Although the length of hospital stay decreased, total medical costs increased in all age groups and both sexes between 2011 and 2019 (all p < 0.001). When compared with the control group, the CDI-attributable length of hospital stay and medical cost were greater by 15.3 days and KRW 3413 (×103), respectively, after matching. In conclusion, CDI incidence, particularly among the elderly population with comorbidities, has been increasing. In addition, the length of hospital stay and total medical costs of the CDI group were greater than those of the control group.

Impact of time to treatment in first occurrence, non-severe Clostridioides difficile infection for elderly patients: are we waiting too long to treat?

Objective

Data evaluating timeliness of antibiotic therapy in Clostridioides difficile infections (CDI) are not well established. The study's purpose was to evaluate the impact of time-to-CDI treatment on disease progression.

Methods

A case-control study was performed among hospitalized patients with CDI from 1/2018 to 2/2022. Inclusion criteria were age ≥65 years, first occurrence, non-severe CDI at symptom onset, and CDI treatment for ≥72 hours. Cases included patients who progressed to severe or fulminant CDI; controls were patients without CDI progression. Time to CDI treatment was evaluated in three ways: a classification and regression tree (CART)-defined threshold, time as a continuous variable, and time as a categorical variable.

Results

272 patients were included; 136 with CDI progression, 136 patients without. The median (IQR) age was 74 (69-81) years, 167 (61%) were women, and 108 (40%) were immunosuppressed. CDI progression patients more commonly were toxin positive (66 [49%] vs 52 [38%], P = .087) with hospital-acquired disease (57 [42%] vs 29 [21%], P < 0.001). A CART-derived breakpoint for optimal time-to-CDI treatment of 64 hours established early (184, 68%) and delayed treatment (88, 32%). When accounting for confounding variables, delayed CDI treatment was associated with disease progression (adjOR, 4.6; 95%CI, 2.6-8.2); this was observed regardless of how time-to-CDI-active therapy was evaluated (continuous adjOR, 1.02; categorical adjOR, 2.11).

Conclusion

Delayed CDI treatment was associated with disease progression and could represent an important antimicrobial stewardship measure with future evaluation.

Implementation strategies for hospital-based probiotic administration in a stepped-wedge cluster randomized trial design for preventing hospital-acquired Clostridioides difficile infection

BACKGROUND

Clostridioides difficile infection (CDI) is associated with considerable morbidity and mortality in hospitalized patients, especially among older adults. Probiotics have been evaluated to prevent hospital-acquired (HA) CDI in patients who are receiving systemic antibiotics, but the implementation of timely probiotic administration remains a challenge. We evaluated methods for effective probiotic implementation across a large health region as part of a study to assess the real-world effectiveness of a probiotic to prevent HA-CDI (Prevent CDI-55 +).

METHODS

We used a stepped-wedge cluster-randomized controlled trial across four acute-care adult hospitals (n = 2,490 beds) to implement the use of the probiotic Bio-K + ® (Lactobacillus acidophilus CL1285®, L. casei LBC80R® and L. rhamnosus CLR2®; Laval, Quebec, Canada) in patients 55 years and older receiving systemic antimicrobials. The multifaceted probiotic implementation strategy included electronic clinical decision support, local site champions, and both health care provider and patient educational interventions. Focus groups were conducted during study implementation to identify ongoing barriers and facilitators to probiotic implementation, guiding needed adaptations of the implementation strategy. Focus groups were thematically analyzed using the Theoretical Domains Framework and the Consolidated Framework of Implementation Research.

RESULTS

A total of 340 education sessions with over 1,800 key partners and participants occurred before and during implementation in each of the four hospitals. Site champions were identified for each included hospital, and both electronic clinical decision support and printed educational resources were available to health care providers and patients. A total of 15 individuals participated in 2 focus group and 7 interviews. Key barriers identified from the focus groups resulted in adaptation of the electronic clinical decision support and the addition of nursing education related to probiotic administration. As a result of modifying implementation strategies for identified behaviour change barriers, probiotic adherence rates were from 66.7 to 75.8% at 72 h of starting antibiotic therapy across the four participating acute care hospitals.

CONCLUSIONS

Use of a barrier-targeted multifaceted approach, including electronic clinical decision support, education, focus groups to guide the adaptation of the implementation plan, and local site champions, resulted in a high probiotic adherence rate in the Prevent CDI-55 + study.

Impact of Clostridioides difficile length of treatment on rates of recurrence in patients on concurrent antibiotics

BACKGROUND

Clostridioides difficile infection (CDI) is principally health care-associated, with a substantial impact on morbidity and mortality. The guidelines recommend CDI therapy for 10 days; however, it is often extended in practice when concurrent antibiotics are used. The impact of the extended duration of therapy remains unclear.

OBJECTIVE

To compare the rates of CDI recurrence in patients receiving standard duration of therapy (SDT) with those receiving extended duration of therapy (EDT) for the treatment of hospital-acquired CDI (HA-CDI) while receiving concurrent antibiotics.

METHODS

A retrospective chart review was conducted between October 2017 and 2019. Adult HA-CDI patients who received a minimum 10 days of CDI therapy and were on concurrent antibiotics were stratified into SDT and EDT groups. Rates of CDI recurrence (at 90 and 180 days) and incidence of new-onset vancomycin-resistant enterococcus (VRE) were compared.

RESULTS

Two hundred twenty-three patients met the inclusion criteria (SD-106, EDT-117). CDI recurrence rates at 90 and 180 days were not statistically significant between SDT and EDT groups (22% vs 26%, P = .40% and 26% vs 31%, P = .47). Although the incidence of VRE within the extended group was higher, it was not statistically significant (6% vs 9%, P = .29).

CONCLUSIONS

No significant difference in rates of recurrence or new-onset VRE was observed between SDT and EDT in HA-CDI patients.

Clostridioides difficile infection in mechanically ventilated critically ill patients: A nested cohort study

INTRODUCTION

Clostridioides difficile infection (CDI) is a serious complication of critical illness. The objective of the study was to determine its incidence, prevalence, timing, severity, predictors, and outcomes.

METHODS

We performed a prospective nested cohort study of CDI within a randomized trial comparing Lactobacillus rhamnosus GG to placebo. We adjudicated cases of CDI using standardized definitions, assessed timing (pre-ICU, in ICU, post-ICU) and severity. We analyzed risk factors and outcomes.

RESULTS

Of 2650 patients, 86 were diagnosed with CDI during 90,833 hospital-days (0.95/1000 hospital-days); CDI prevalence was 3.2%. CDI incidence varied in timing; 0.3% patients had CDI pre-ICU, 2.2% in the ICU; an 0.8% developed CDI post-ICU. Relapse or recurrence of CDI was documented in 9.3% patients. Infections were mild/moderate in severity. Complications included septic shock (26.7%), organ failure (16.3%), and toxic megacolon requiring colectomy (1.2%). No risk factors for CDI were identified. CDI was not associated with hospital mortality. The duration of hospital stay was longer for those who had CDI compared those who did not, CONCLUSION: CDI was uncommon, severity was mild to moderate and not associated with mortality however CDI was associated with a longer hospital stay.

Future Applications of Metagenomic Next-Generation Sequencing for Infectious Diseases Diagnostics

Metagenomic next-generation sequencing (mNGS) has the theoretical capacity to detect any microbe present in a host. mNGS also has the potential to infer a pathogen's phenotypic characteristics, including the ability to colonize humans, cause disease, and resist treatment. Concurrent host nucleic acid sequencing can assess the infected individual's physiological state, including characterization and appropriateness of the immune response. When the pathogen cannot be identified, host RNA sequencing may help infer the organism's nature. While the full promise of mNGS remains far from realization, the potential ability to identify all microbes in a complex clinical sample, assess each organism's virulence and antibiotic susceptibility traits, and simultaneously characterize the host's response to infection provide opportunities for mNGS to supplant existing technologies and become the primary method of infectious diseases diagnostics.

THAs Performed Within 6 Months of Clostridioides difficile Infection Are Associated with Increased Risk of 90-Day Complications

BACKGROUND

Clostridioides difficile infection (CDI) may be a surrogate for poor patient health. As such, a history of CDI before THA may be used to identify patients at higher risk for postoperative CDI and complications after THA. Investigations into the associations between CDI before THA and postoperative CDI and complications are lacking.

QUESTIONS/PURPOSES

We compared the (1) frequency and potential risk factors for CDI after THA, (2) the frequency of 90-day complications after THA in patients with and without a history of CDI, and (3) the length of stay and frequency of readmissions in patients experiencing CDIs more than 6 months before THA, patients experiencing CDIs in the 6 months before THA, and patients without a history of CDI.

METHODS

Patients undergoing primary THA from 2010 to 2019 were identified in the PearlDiver database using ICD and Current Procedural Terminology codes (n = 714,185). This analysis included Medicare, Medicaid, and private insurance claims across the United States with the ability to perform longitudinal and costs analysis using large patient samples to improve generalizability and reduce error rates. Patients with a history of CDI before THA (n = 5196) were stratified into two groups: those with CDIs that occurred more than 6 months before THA (n = 4003, median 2.2 years [interquartile range 1.2 to 3.6]) and those experiencing CDIs within the 6 months before THA (n = 1193). These patients were compared with the remaining 708,989 patients without a history of CDI before THA. Multivariable logistic regression was used to evaluate the association of risk factors and incidence of 90-day postoperative CDI in patients with a history of CDI. Variables such as antibiotic use, proton pump inhibitor use, chemotherapy, and inflammatory bowel disease were included in the models. Chi-square and unadjusted odds ratios with 95% confidence intervals were used to compare complication frequencies. A Bonferroni correction adjusted the p value significance threshold to < 0.003.

RESULTS

Prior CDI during either timespan was associated with higher unadjusted odds for postoperative CDI (CDI > 6 months before THA: OR 8.44 [95% CI 6.95 to 10.14]; p < 0.001; CDI ≤ 6 months before THA: OR 49.92 [95% CI 42.26 to 58.54]; p < 0.001). None of the risk factors included in the regression were associated with increased odds for postoperative CDI in patients with preoperative history of CDI. Patients with a history of CDI before THA were associated with higher unadjusted odds for every 90-day complication compared with patients without a history of CDI before THA. CDI during either timespan was associated with longer lengths of stay (no CDI before THA: 3.8 days; CDI > 6 months before THA: 4.5 days; CDI ≤ 6 months before THA: 5.3 days; p < 0.001) and 90-day readmissions (CDI > 6 months before THA: OR 2.21 [95% CI 1.98 to 2.47]; p < 0.001; CDI ≤ 6 months before THA: OR 3.39 [95% CI 2.85 to 4.02]; p < 0.001).

CONCLUSION

Having CDI before THA was associated with higher odds of postoperative CDI compared with patients without a history of CDI. A history of CDI within the 6 months before THA was associated with the greatest odds for postoperative complications and readmissions. Providers should strongly consider delaying THA until 6 months after CDI, if possible, to provide adequate time for patient recovery and eradication of infection.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Costs Associated with the Treatment of Clostridioides Difficile Infections

Background: Clostridioides difficile, as the main cause of infectious diarrhoea in hospitalised patients, is a considerable challenge for medical personnel (hospital environment) who have direct contact with the patient, as well as being of interest to public health specialists. Financial issues related to the occurrence of the above-mentioned micro-organism are being increasingly raised. Due to the scale of the phenomenon, we are beginning to pay attention to the significant system costs caused by the diagnosis and treatment of CDI infection and its complications. Studies indicate that the nosocomial infection of C. difficile complicates hospitalisation, by increasing the cost by more than half and extending patient’s stay by an average of 3.6 days. Material and methods: The aim of this study was to attempt to calculate the estimated costs associated with the prolonged hospitalisation of patients with nosocomial CDI infection, using the example of a hospital in Lodz. A total of 53 completed hospitalisations of patients treated in the period of January–August 2018 were analysed, during which hospital Clostridioides difficile infection was identified. For the purposes of this study, statistical data collected in the hospital’s IT system were also analysed, covering 44,868 hospitalisations in the Jan–Aug 2018 period, during which no hospital infection occurred. They was a control group, in which the analysed cases were compared. The obtained data in the study determined how long each patient with Clostridioides difficile infection stayed in the hospital (from the moment infection was diagnosed until the day of hospital discharge), and which diagnosis related groups (DRG) (according to National Health Fund guidelines) were assigned. The average length of patient stay without infection within a given DRG group in each hospital ward was also determined. The collected materials became the initial point for the final analysis of hospital costs and the length of hospital stay caused by Clostridioides difficile infection. Results: Clostridioides difficile infection extended the hospital stay by an average of almost 12 days. The average cost of prolonged hospitalisation due to CDI infection (according to the average cost per person-day) was about PLN 7148 (1664 EUR), which gave a total value of about PLN 378,860.6 (88,240.5 EUR) in the examined period. At the same time, the average expenditure from the National Health Fund for hospitalisation due to CDI infections increased by about PLN 6627 (1542.8 EUR), which in the analysed period translated into over PLN 351,232.0 (81,505.5 EUR) (according to settlements with the National Health Fund). The outcome indicates that there is a clear relation between CDI and the anticipated length of hospitalisation of patients without an infection.

Clostridioides difficile infections in Alberta: The validity of administrative data using ICD-10 diagnostic codes for CDI surveillance versus clinical infection surveillance

BACKGROUND

Clostridioides difficile infection (CDI) is one of the most common health care-associated infections. This study assessed the validity of the Discharge Abstract Database (DAD) compared to a traditional clinical surveillance method for identifying CDI.

METHODS

Retrospective analysis of all DAD records with International Statistical Classification of Diseases and Related Health Problems 10th Revision (ie, ICD-10) diagnostic code A04.7 (enterocolitis due to CDI) between April 2015 and March 2019 were compared to a clinical dataset of positive inpatient CDI for all acute care facilities in Alberta, Canada. Sensitivity and positive predictive values were calculated using R version 3.6.0.

RESULTS

The DAD had a sensitivity of 85.0% (95% confidence interval: 84.1%-85.8%) and a positive predictive value of 80.0% (95% confidence interval: 79.2%-80.0%). The CDI rate per 1,000 admissions over the study period was 28% higher in the DAD compared to Infection Prevention and Control surveillance.

DISCUSSION

The DAD does not distinguish symptomatic cases from asymptomatic cases and so indicators to identify symptomatic disease would need to be applied, potentially through a linkage to antibiotic treatment orders available in patient management systems.

CONCLUSIONS

The DAD is moderately sensitive for identifying symptomatic CDI cases in Alberta, Canada and caution should be applied when interpreting rates based on administrative data.

Clinical characteristics and prognostic factors of extraintestinal infection caused by Clostridioides difficile: analysis of 60 consecutive cases

Data regarding extraintestinal Clostridioides difficile infections (ECDIs) remain scarce and anecdotal. We conducted a retrospective cohort study to investigate characteristics and prognostic factors in patients with ECDI. From January 1997 through December 2018, 60 patients were enrolled and divided into three groups as follows: group A (gastrointestinal [GI] disruption caused by malignancy, n = 13); group B (GI disruption from causes other than malignancy, n = 25); group C (no GI disruption, n = 22). GI disruption was defined as compromised integrity of the GI tract caused by abdominal surgery, perforation, malignancy, enterocolitis, or bleeding. The incidence of ECDI was 2.53 per 100,000 admissions. The most common specimens yielded C. difficile were blood (36.7%), peritoneal fluid (20.0%), and abscesses (16.7%). Six patients (10.0%) had confirmed C. difficile enterocolitis, and 36 patients (60.0%) had a polymicrobial infection. C. difficile bacteremia was significantly more common in group A patients than those in groups B or C (53.8% vs. 48.0% vs. 13.6%, p = 0.02), as was the 30-day mortality rate (69.2% vs. 12.0% vs. 18.2%, respectively; p < 0.001). In multivariate analysis, group A (adjusted odds ratio [aOR], 17.32; 95% confidence interval [CI], 2.96-101.21; p = 0.002) and an age of > 65 years (aOR, 7.09; 95% CI, 1.31-38.45; p = 0.02) were independent risk factors for 30-day mortality. ECDI was uncommonly associated with C. difficile enterocolitis. Two factors, GI disruption caused by malignancy, and old age, were associated with significantly poorer short-term outcomes.

Antimicrobial susceptibility of Clostridioides difficile isolated from diarrhoeal stool specimens of Canadian patients: summary of results from the Canadian Clostridioides difficile (CAN-DIFF) surveillance study from 2013 to 2017

Objectives

To summarize data generated by the Canadian Clostridioides difficile (CAN-DIFF) surveillance study from 2013 to 2017.

Methods

Isolates of C. difficile (n = 2158) were cultured from toxin-positive diarrhoeal stool specimens submitted by eight hospital laboratories to a coordinating laboratory. Antimicrobial susceptibility testing was performed according to the CLSI agar dilution method (M11, 2018). Isolate ribotypes were determined using an international, standardized, high-resolution capillary gel-based electrophoresis protocol.

Results

Of the 2158 isolates of C. difficile, 2133 (98.8%) had vancomycin MICs ≤2 mg/L [i.e. were vancomycin susceptible (EUCAST breakpoint tables, v 9.0, 2019) or WT (CLSI M100, 29th edition, 2019)]. Fidaxomicin MICs were lower than those of all other agents tested (MIC90, 0.5 mg/L); however, one isolate with a fidaxomicin MIC of &gt;8 mg/L was identified. Metronidazole MICs ranged from 0.12 to 4 mg/L; all isolates were metronidazole susceptible by the CLSI breakpoint (≤8 mg/L) compared with 96.8% susceptible by the EUCAST breakpoint (≤2 mg/L). In total, 182 different ribotypes were identified from 2013 to 2017. The most common ribotypes identified were 027 (19.3% of isolates) and 106 (8.2%). Ribotype 027 isolates were frequently moxifloxacin resistant (87.3% of isolates) and MDR (48.6%), associated with vancomycin (10/25, 40.0%) and metronidazole (58/69, 84.1%) resistance and from patients aged ≥80 years. The prevalence of ribotype 027 decreased significantly (P &lt; 0.0001) from 2013 (27.5%) to 2017 (9.0%) and was replaced by increases in ribotype 106 (P = 0.0003) and multiple less common ribotypes.

Conclusions

Periodic surveillance is required to monitor clinical isolates of C. difficile for changes to in vitro susceptibility testing profiles and ribotype evolution.