1
|
Guh AY, Fridkin S, Goodenough D, Winston LG, Johnston H, Basiliere E, Olson D, Wilson CD, Watkins JJ, Korhonen L, Gerding DN. Potential underreporting of treated patients using a Clostridioides difficile testing algorithm that screens with a nucleic acid amplification test. Infect Control Hosp Epidemiol 2024; 45:590-598. [PMID: 38268440 PMCID: PMC11027077 DOI: 10.1017/ice.2023.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/25/2023] [Accepted: 11/01/2023] [Indexed: 01/26/2024]
Abstract
OBJECTIVE Patients tested for Clostridioides difficile infection (CDI) using a 2-step algorithm with a nucleic acid amplification test (NAAT) followed by toxin assay are not reported to the National Healthcare Safety Network as a laboratory-identified CDI event if they are NAAT positive (+)/toxin negative (-). We compared NAAT+/toxin- and NAAT+/toxin+ patients and identified factors associated with CDI treatment among NAAT+/toxin- patients. DESIGN Retrospective observational study. SETTING The study was conducted across 36 laboratories at 5 Emerging Infections Program sites. PATIENTS We defined a CDI case as a positive test detected by this 2-step algorithm during 2018-2020 in a patient aged ≥1 year with no positive test in the previous 8 weeks. METHODS We used multivariable logistic regression to compare CDI-related complications and recurrence between NAAT+/toxin- and NAAT+/toxin+ cases. We used a mixed-effects logistic model to identify factors associated with treatment in NAAT+/toxin- cases. RESULTS Of 1,801 cases, 1,252 were NAAT+/toxin-, and 549 were NAAT+/toxin+. CDI treatment was given to 866 (71.5%) of 1,212 NAAT+/toxin- cases versus 510 (95.9%) of 532 NAAT+/toxin+ cases (P < .0001). NAAT+/toxin- status was protective for recurrence (adjusted odds ratio [aOR], 0.65; 95% CI, 0.55-0.77) but not CDI-related complications (aOR, 1.05; 95% CI, 0.87-1.28). Among NAAT+/toxin- cases, white blood cell count ≥15,000/µL (aOR, 1.87; 95% CI, 1.28-2.74), ≥3 unformed stools for ≥1 day (aOR, 1.90; 95% CI, 1.40-2.59), and diagnosis by a laboratory that provided no or neutral interpretive comments (aOR, 3.23; 95% CI, 2.23-4.68) were predictors of CDI treatment. CONCLUSION Use of this 2-step algorithm likely results in underreporting of some NAAT+/toxin- cases with clinically relevant CDI. Disease severity and laboratory interpretive comments influence treatment decisions for NAAT+/toxin- cases.
Collapse
Affiliation(s)
- Alice Y. Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Scott Fridkin
- Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Decatur, Georgia
| | - Dana Goodenough
- Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Decatur, Georgia
- Atlanta Veterans’ Affairs Medical Center, Decatur, Georgia
| | - Lisa G. Winston
- University of California, San Francisco, School of Medicine, San Francisco, California
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado
| | | | - Danyel Olson
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut
| | | | | | - Lauren Korhonen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dale N. Gerding
- Edward Hines, Jr., Veterans’ Affairs Hospital, Hines, Illinois
| |
Collapse
|
2
|
Guh AY, Li R, Korhonen L, Winston LG, Parker E, Czaja CA, Johnston H, Basiliere E, Meek J, Olson D, Fridkin SK, Wilson LE, Perlmutter R, Holzbauer SM, D’Heilly P, Phipps EC, Flores KG, Dumyati GK, Pierce R, Ocampo VLS, Wilson CD, Watkins JJ, Gerding DN, McDonald LC. Characteristics of Patients With Initial Clostridioides difficile Infection (CDI) That Are Associated With Increased Risk of Multiple CDI Recurrences. Open Forum Infect Dis 2024; 11:ofae127. [PMID: 38577028 PMCID: PMC10993058 DOI: 10.1093/ofid/ofae127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
Background Because interventions are available to prevent further recurrence in patients with recurrent Clostridioides difficile infection (rCDI), we identified predictors of multiple rCDI (mrCDI) in adults at the time of presentation with initial CDI (iCDI). Methods iCDI was defined as a positive C difficile test in any clinical setting during January 2018-August 2019 in a person aged ≥18 years with no known prior positive test. rCDI was defined as a positive test ≥14 days from the previous positive test within 180 days after iCDI; mrCDI was defined as ≥2 rCDI. We performed multivariable logistic regression analysis. Results Of 18 829 patients with iCDI, 882 (4.7%) had mrCDI; 437 with mrCDI and 7484 without mrCDI had full chart reviews. A higher proportion of patients with mrCDI than without mrCDI were aged ≥65 years (57.2% vs 40.7%; P < .0001) and had healthcare (59.1% vs 46.9%; P < .0001) and antibiotic (77.3% vs 67.3%; P < .0001) exposures in the 12 weeks preceding iCDI. In multivariable analysis, age ≥65 years (adjusted odds ratio [aOR], 1.91; 95% confidence interval [CI], 1.55-2.35), chronic hemodialysis (aOR, 2.28; 95% CI, 1.48-3.51), hospitalization (aOR, 1.64; 95% CI, 1.33-2.01), and nitrofurantoin use (aOR, 1.95; 95% CI, 1.18-3.23) in the 12 weeks preceding iCDI were associated with mrCDI. Conclusions Patients with iCDI who are older, on hemodialysis, or had recent hospitalization or nitrofurantoin use had increased risk of mrCDI and may benefit from early use of adjunctive therapy to prevent mrCDI. If confirmed, these findings could aid in clinical decision making and interventional study designs.
Collapse
Affiliation(s)
- Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rongxia Li
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lauren Korhonen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lisa G Winston
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Erin Parker
- California Emerging Infections Program, Oakland, California, USA
| | | | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver,Colorado, USA
| | | | - James Meek
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut, USA
| | - Danyel Olson
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut, USA
| | | | - Lucy E Wilson
- University of Maryland Baltimore County, Baltimore, Maryland, USA
| | | | - Stacy M Holzbauer
- Minnesota Department of Health, St Paul, Minnesota, USA
- Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Erin C Phipps
- New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, New Mexico, USA
| | - Kristina G Flores
- New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, New Mexico, USA
| | - Ghinwa K Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York, USA
| | | | | | | | | | - Dale N Gerding
- Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois, USA
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
3
|
Abstract
The Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center was the first hospital in San Francisco and one of the first in California to successfully operationalize the administration of Covid-19 vaccines to hospitalized patients. Between February and July of 2021, inpatient clinicians administered 526 Covid-19 vaccines with zero wasted doses. More than 80% of enrolled patients were fully vaccinated by the Inpatient Vaccine Program (IP Program) while admitted or after discharge. The IP Program identified and mitigated 12 workflow considerations to ensure a sustainable system. The infrastructure remains flexible enough to adapt to evolving vaccination eligibility, including supplemental and booster dose indications. Covid-19 vaccination in an academic, safety-net hospital provides an opportunity to mitigate vaccination disparities and access vulnerable, unvaccinated populations.
Collapse
Affiliation(s)
- Dana Freiser
- Medical-Surgical Performance Improvement Coordinator, Inpatient Vaccine Lead, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Merjo Roca
- Nurse Manager, Urgent Care Clinic, Outpatient Vaccine Clinic and Alternative Testing Site, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Tony Chung
- Pharmacy Business Operations Supervisor, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Tanvi Bhakta
- Nurse Manager, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Lisa G. Winston
- Chief of Staff and Hospital Epidemiologist, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Professor, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Gabriel M. Ortiz
- Medical Director of Medical-Surgical Care Areas, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Associate Professor, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
4
|
Winston LG, Winkler ML, Kheterpal A, Villalba JA. Case 36-2021: A 22-Year-Old Man with Pain and Erythema of the Left Hand. N Engl J Med 2021; 385:2078-2086. [PMID: 34818483 DOI: 10.1056/nejmcpc2107357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Lisa G Winston
- From the Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, and the Department of Medicine, University of California, San Francisco - both in San Francisco (L.G.W.); and the Departments of Medicine (M.L.W.), Radiology (A.K.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (M.L.W.), Radiology (A.K.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| | - Marisa L Winkler
- From the Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, and the Department of Medicine, University of California, San Francisco - both in San Francisco (L.G.W.); and the Departments of Medicine (M.L.W.), Radiology (A.K.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (M.L.W.), Radiology (A.K.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| | - Arvin Kheterpal
- From the Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, and the Department of Medicine, University of California, San Francisco - both in San Francisco (L.G.W.); and the Departments of Medicine (M.L.W.), Radiology (A.K.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (M.L.W.), Radiology (A.K.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| | - Julian A Villalba
- From the Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, and the Department of Medicine, University of California, San Francisco - both in San Francisco (L.G.W.); and the Departments of Medicine (M.L.W.), Radiology (A.K.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (M.L.W.), Radiology (A.K.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| |
Collapse
|
5
|
Affiliation(s)
- Brett W Dietz
- From the Divisions of Rheumatology (B.W.D., M.M.), HIV, Infectious Diseases, and Global Medicine (L.G.W.), and Infectious Diseases (J.E.K.), Department of Medicine, University of California, San Francisco, and the San Francisco Veterans Affairs Health System (B.W.D.) - both in San Francisco
| | - Lisa G Winston
- From the Divisions of Rheumatology (B.W.D., M.M.), HIV, Infectious Diseases, and Global Medicine (L.G.W.), and Infectious Diseases (J.E.K.), Department of Medicine, University of California, San Francisco, and the San Francisco Veterans Affairs Health System (B.W.D.) - both in San Francisco
| | - Jane E Koehler
- From the Divisions of Rheumatology (B.W.D., M.M.), HIV, Infectious Diseases, and Global Medicine (L.G.W.), and Infectious Diseases (J.E.K.), Department of Medicine, University of California, San Francisco, and the San Francisco Veterans Affairs Health System (B.W.D.) - both in San Francisco
| | - Mary Margaretten
- From the Divisions of Rheumatology (B.W.D., M.M.), HIV, Infectious Diseases, and Global Medicine (L.G.W.), and Infectious Diseases (J.E.K.), Department of Medicine, University of California, San Francisco, and the San Francisco Veterans Affairs Health System (B.W.D.) - both in San Francisco
| |
Collapse
|
6
|
Whitman JD, Pham P, Bern C, Dekker EM, Haller BL, Jain V, Winston LG. Significant and sustained decrease in non-SARS-CoV-2 respiratory viral infections during COVID-19 public health interventions. medRxiv 2021:2021.05.11.21256147. [PMID: 34013283 PMCID: PMC8132257 DOI: 10.1101/2021.05.11.21256147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Public health interventions to decrease the spread of SARS-CoV-2 were largely implemented in the United States during spring 2020. This study evaluates the additional effects of these interventions on non-SARS-CoV-2 respiratory viral infections from a single healthcare system in the San Francisco Bay Area. The results of a respiratory pathogen multiplex polymerase chain reaction panel intended for inpatient admissions were analyzed by month between 2019 and 2020. We found major decreases in the proportion and diversity of non-SARS-CoV-2 respiratory viral illnesses in all months following masking and shelter-in-place ordinances. These findings suggest real-world effectiveness of nonpharmaceutical interventions on droplet-transmitted respiratory infections.
Collapse
Affiliation(s)
- Jeffrey D. Whitman
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Phong Pham
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Caryn Bern
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Elaine M. Dekker
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Barbara L. Haller
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Vivek Jain
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Lisa G. Winston
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| |
Collapse
|
7
|
Guh AY, Hatfield KM, Winston LG, Martin B, Johnston H, Brousseau G, Farley MM, Wilson L, Perlmutter R, Phipps EC, Dumyati GK, Nelson D, Hatwar T, Kainer MA, Paulick AL, Karlsson M, Gerding DN, McDonald LC. Toxin Enzyme Immunoassays Detect Clostridioides difficile Infection With Greater Severity and Higher Recurrence Rates. Clin Infect Dis 2020; 69:1667-1674. [PMID: 30615074 DOI: 10.1093/cid/ciz009] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/04/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Few data suggest that Clostridioides difficile infections (CDIs) detected by toxin enzyme immunoassay (EIA) are more severe and have worse outcomes than those detected by nucleic acid amplification tests (NAATs) only. We compared toxin- positive and NAAT-positive-only CDI across geographically diverse sites. METHODS A case was defined as a positive C. difficile test in a person ≥1 year old with no positive tests in the prior 8 weeks. Cases were detected during 2014-2015 by a testing algorithm (specimens initially tested by glutamate dehydrogenase and toxin EIA; if discordant results, specimens were reflexed to NAAT) and classified as toxin positive or NAAT positive only. Medical charts were reviewed. Multivariable logistic regression models were used to compare CDI-related complications, recurrence, and 30-day mortality between the 2 groups. RESULTS Of 4878 cases, 2160 (44.3%) were toxin positive and 2718 (55.7%) were NAAT positive only. More toxin-positive than NAAT-positive-only cases were aged ≥65 years (48.2% vs 38.0%; P < .0001), had ≥3 unformed stools for ≥1 day (43.9% vs 36.6%; P < .0001), and had white blood cell counts ≥15 000 cells/µL (31.4% vs 21.4%; P < .0001). In multivariable analysis, toxin positivity was associated with recurrence (adjusted odds ratio [aOR], 1.89; 95% confidence interval [CI], 1.61-2.23), but not with CDI-related complications (aOR, 0.91; 95% CI, .67-1.23) or 30-day mortality (aOR, 0.95; 95% CI, .73-1.24). CONCLUSIONS Toxin-positive CDI is more severe, but there were no differences in adjusted CDI-related complication and mortality rates between toxin-positive and NAAT-positive-only CDI that were detected by an algorithm that utilized an initial glutamate dehydrogenase screening test.
Collapse
Affiliation(s)
- Alice Y Guh
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Lisa G Winston
- School of Medicine, University of California, San Francisco
| | | | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver
| | | | - Monica M Farley
- Emory University School of Medicine, Atlanta, Georgia.,Veterans Affairs Medical Center, Atlanta, Georgia
| | | | | | - Erin C Phipps
- University of New Mexico, Albuquerque.,New Mexico Emerging Infections Program, Albuquerque
| | - Ghinwa K Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Nashville
| | - Deborah Nelson
- New York Emerging Infections Program and University of Rochester Medical Center, Nashville
| | - Trupti Hatwar
- New York Emerging Infections Program and University of Rochester Medical Center, Nashville
| | | | | | - Maria Karlsson
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dale N Gerding
- Stritch School of Medicine, Loyola University Chicago, Maywood.,Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois
| | | |
Collapse
|
8
|
Guh AY, Mu Y, Winston LG, Johnston H, Olson D, Farley MM, Wilson LE, Holzbauer SM, Phipps EC, Dumyati GK, Beldavs ZG, Kainer MA, Karlsson M, Gerding DN, McDonald LC. Trends in U.S. Burden of Clostridioides difficile Infection and Outcomes. N Engl J Med 2020; 382:1320-1330. [PMID: 32242357 PMCID: PMC7861882 DOI: 10.1056/nejmoa1910215] [Citation(s) in RCA: 421] [Impact Index Per Article: 105.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Efforts to prevent Clostridioides difficile infection continue to expand across the health care spectrum in the United States. Whether these efforts are reducing the national burden of C. difficile infection is unclear. METHODS The Emerging Infections Program identified cases of C. difficile infection (stool specimens positive for C. difficile in a person ≥1 year of age with no positive test in the previous 8 weeks) in 10 U.S. sites. We used case and census sampling weights to estimate the national burden of C. difficile infection, first recurrences, hospitalizations, and in-hospital deaths from 2011 through 2017. Health care-associated infections were defined as those with onset in a health care facility or associated with recent admission to a health care facility; all others were classified as community-associated infections. For trend analyses, we used weighted random-intercept models with negative binomial distribution and logistic-regression models to adjust for the higher sensitivity of nucleic acid amplification tests (NAATs) as compared with other test types. RESULTS The number of cases of C. difficile infection in the 10 U.S. sites was 15,461 in 2011 (10,177 health care-associated and 5284 community-associated cases) and 15,512 in 2017 (7973 health care-associated and 7539 community-associated cases). The estimated national burden of C. difficile infection was 476,400 cases (95% confidence interval [CI], 419,900 to 532,900) in 2011 and 462,100 cases (95% CI, 428,600 to 495,600) in 2017. With accounting for NAAT use, the adjusted estimate of the total burden of C. difficile infection decreased by 24% (95% CI, 6 to 36) from 2011 through 2017; the adjusted estimate of the national burden of health care-associated C. difficile infection decreased by 36% (95% CI, 24 to 54), whereas the adjusted estimate of the national burden of community-associated C. difficile infection was unchanged. The adjusted estimate of the burden of hospitalizations for C. difficile infection decreased by 24% (95% CI, 0 to 48), whereas the adjusted estimates of the burden of first recurrences and in-hospital deaths did not change significantly. CONCLUSIONS The estimated national burden of C. difficile infection and associated hospitalizations decreased from 2011 through 2017, owing to a decline in health care-associated infections. (Funded by the Centers for Disease Control and Prevention.).
Collapse
Affiliation(s)
- Alice Y Guh
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Yi Mu
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Lisa G Winston
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Helen Johnston
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Danyel Olson
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Monica M Farley
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Lucy E Wilson
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Stacy M Holzbauer
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Erin C Phipps
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Ghinwa K Dumyati
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Zintars G Beldavs
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Marion A Kainer
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Maria Karlsson
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - Dale N Gerding
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| | - L Clifford McDonald
- From the Division of Healthcare Quality Promotion (A.Y.G., Y.M., M.K., L.C.M.) and the Career Epidemiology Field Officer Program (S.M.H.), Centers for Disease Control and Prevention, Emory University School of Medicine (M.M.F.), and the Veterans Affairs Medical Center (M.M.F.) - all in Atlanta; the University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); the Colorado Department of Public Health and Environment, Denver (H.J.); the Connecticut Emerging Infections Program, Yale School of Public Health, New Haven (D.O.); the University of Maryland Baltimore County and the Maryland Department of Health, Baltimore (L.E.W.); the Minnesota Department of Health, St. Paul (S.M.H.); the University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); the New York Emerging Infections Program and University of Rochester Medical Center, Rochester (G.K.D.); the Oregon Health Authority, Portland (Z.G.B.); the Tennessee Department of Health, Nashville (M.A.K.); and Stritch School of Medicine, Loyola University Chicago, Maywood, and the Edward Hines, Jr. Veterans Affairs Hospital, Hines - both in Illinois (D.N.G.)
| |
Collapse
|
9
|
Affiliation(s)
- Rabih M Geha
- From the Department of Medicine, University of California, San Francisco (R.M.G., G.D., L.G.W.), Medical Service, San Francisco VA Medical Center (R.M.G., G.D.), and Zuckerberg San Francisco General Hospital and Trauma Center (L.G.W.) - all in San Francisco; and the Department of Pathology, Johns Hopkins University School of Medicine (T.S.K.), and the Department of Medicine, Johns Hopkins Hospital and Johns Hopkins University School of Medicine (R.M.) - both in Baltimore
| | - Gurpreet Dhaliwal
- From the Department of Medicine, University of California, San Francisco (R.M.G., G.D., L.G.W.), Medical Service, San Francisco VA Medical Center (R.M.G., G.D.), and Zuckerberg San Francisco General Hospital and Trauma Center (L.G.W.) - all in San Francisco; and the Department of Pathology, Johns Hopkins University School of Medicine (T.S.K.), and the Department of Medicine, Johns Hopkins Hospital and Johns Hopkins University School of Medicine (R.M.) - both in Baltimore
| | - Lisa G Winston
- From the Department of Medicine, University of California, San Francisco (R.M.G., G.D., L.G.W.), Medical Service, San Francisco VA Medical Center (R.M.G., G.D.), and Zuckerberg San Francisco General Hospital and Trauma Center (L.G.W.) - all in San Francisco; and the Department of Pathology, Johns Hopkins University School of Medicine (T.S.K.), and the Department of Medicine, Johns Hopkins Hospital and Johns Hopkins University School of Medicine (R.M.) - both in Baltimore
| | - Thomas S Kickler
- From the Department of Medicine, University of California, San Francisco (R.M.G., G.D., L.G.W.), Medical Service, San Francisco VA Medical Center (R.M.G., G.D.), and Zuckerberg San Francisco General Hospital and Trauma Center (L.G.W.) - all in San Francisco; and the Department of Pathology, Johns Hopkins University School of Medicine (T.S.K.), and the Department of Medicine, Johns Hopkins Hospital and Johns Hopkins University School of Medicine (R.M.) - both in Baltimore
| | - Reza Manesh
- From the Department of Medicine, University of California, San Francisco (R.M.G., G.D., L.G.W.), Medical Service, San Francisco VA Medical Center (R.M.G., G.D.), and Zuckerberg San Francisco General Hospital and Trauma Center (L.G.W.) - all in San Francisco; and the Department of Pathology, Johns Hopkins University School of Medicine (T.S.K.), and the Department of Medicine, Johns Hopkins Hospital and Johns Hopkins University School of Medicine (R.M.) - both in Baltimore
| |
Collapse
|
10
|
Skrobarcek K, Mu Y, Ahern J, Beldavs Z, Brousseau G, Dumyati G, Farley MM, Holzbauer S, Kainer MA, Meek JI, Perlmutter R, Phipps EC, Winston LG, Guh AY. 482. Association between Socioeconomic Status Factors and Incidence of Community-Associated Clostridium difficile Infection Utilizing Factor Analysis—United States, 2014–2015. Open Forum Infect Dis 2018. [PMCID: PMC6253049 DOI: 10.1093/ofid/ofy210.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Traditionally a healthcare-associated infection, Clostridium difficile infection (CDI) is increasingly emerging in communities. Health disparities in CDI exist, but the social determinants of health that influence community-associated (CA) CDI are unknown. We used factor analysis and disparate data sources to identify area-based socioeconomic status (SES) factors associated with CA-CDI incidence. Methods CDC’s Emerging Infections Program conducts population-based CDI surveillance in 35 US counties. A CA-CDI case is defined as a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization in a person aged ≥1 year without a positive test in the prior 8 weeks or an overnight stay in a healthcare facility in the prior 12 weeks. 2014–2015 CA-CDI case addresses were geocoded to a 2010 census tract (CT) and incidence rates were calculated. CT-level SES variables were obtained from the 2011–2015 American Community Survey. The Health Resources and Services Administration provided medically underserved area (MUA) designations. Exploratory factor analysis transformed 15 highly correlated SES variables into threefactors using scree plot and Kaiser criteria: “Low Income,” “Foreign-born,” and “High Income.” To account for CT-level clustering, a negative binomial generalized linear mixed model was used to evaluate the associations of these factors and MUA with CA-CDI incidence, adjusting for age, sex, race and diagnostic test. Results Of 13,903 CA-CDI geocoded cases, 63% were female, 80% were white, and 36% were aged ≥65 years. Annual CA-CDI incidence was 63.4/100,000 persons. In multivariable analysis, “Low Income” (rate ratio [RR]: 1.09; 95% confidence interval [CI]: 1.05–1.13) and “High Income” (RR: 0.90; CI: 0.87–0.93) were significantly associated with CA-CDI incidence. Conclusion Factor analysis was instrumental in identifying key drivers of disparities among interrelated SES variables. Low-income areas were surprisingly associated with higher CA-CDI incidence, given that known CDI risk factors include increased access to healthcare. Understanding how SES factors might impact CA-CDI incidence can inform prevention strategies in low-income areas. Disclosures G. Dumyati, Seres: Scientific Advisor, Consulting fee.
Collapse
Affiliation(s)
- Kimberly Skrobarcek
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yi Mu
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jennifer Ahern
- University of California at Berkeley, Berkeley, California
| | | | - Geoff Brousseau
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Ghinwa Dumyati
- NY Emerging Infections Program, Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York
| | - Monica M Farley
- Department of Medicine, Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia
| | | | - Marion A Kainer
- Communicable and Environmental Diseases and Emergency Preparedness, Tennessee Department of Public Health, Nashville, Tennessee
| | - James I Meek
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut
| | | | - Erin C Phipps
- New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, New Mexico
| | - Lisa G Winston
- Medicine, University of California, San Francisco and Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
11
|
Hatfield KM, Baggs J, Winston LG, Parker E, Martin B, Meek JI, Olson D, Farley MM, Revis A, Holzbauer S, Bye M, Wilson L, Perlmutter R, Phipps EC, Pierce R, Ocampo VLS, Kainer MA, Smith M, McDonald LC, Jernigan JA, Guh A. 492. Long-Term Outcomes of Clostridium difficile Infection Among Medicare Beneficiaries. Open Forum Infect Dis 2018. [PMCID: PMC6253260 DOI: 10.1093/ofid/ofy210.501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is a common healthcare-associated infection, particularly among older adults. We used laboratory-confirmed CDI surveillance data from 8 states participating in the Centers for Disease Control and Prevention’s Emerging Infections Program linked to claims data for Centers for Medicare and Medicaid Services (CMS) beneficiaries to measure variation in 1-year outcomes associated with CDI. Methods A CDI case was defined as a positive C. difficile stool test in 2014 in a person without a positive test in the prior 8 weeks. Cases aged ≥65 years were linked to their CMS beneficiary ID using unique combinations of date of birth, sex, and zip code. Each case was matched to five control beneficiaries who did not link to any case and were residents of the same catchment area. Inclusion criteria were continuous fee-for-service Medicare for the entire study period (1 year before and after event date), and no hospitalization or skilled nursing facility stay with an ICD-9-CM code for CDI in the year prior to their match date. Multivariable logistic regression models were used to compare mortality and hospitalization for 1 year following the event date between beneficiaries with and without CDI, adjusting for age, sex, race, catchment area, chronic conditions, number of hospitalizations in the prior year, and hospitalization status at the time of and 7 days preceding the event date. Results Of 5,097 cases aged ≥65, 3,082 (60%) were linked to a CMS ID, and 1,832 (59%) met inclusion criteria. In crude analysis, 34% of beneficiaries with CDI died within 1 year, compared with 5% of beneficiaries without CDI. Beneficiaries with CDI were also more likely to be hospitalized in the subsequent year (54% vs. 17%). Beneficiaries with CDI had a higher adjusted odds of death (adjusted OR 3.01, 95% CI: 2.46, 3.69) and hospitalization within 1 year (adjusted OR 1.93, 95% CI: 1.65, 2.25) than those without CDI. Conclusion Older adults with CDI were three times more likely to die in the year following infection and nearly two times more likely to be hospitalized compared with those without CDI, revealing independent long-term risk of poor outcomes. This excess morbidity and mortality supports the need to develop novel CDI prevention strategies for this population. Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
- Kelly M Hatfield
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James Baggs
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa G Winston
- Medicine, University of California, San Francisco and Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- California Emerging Infections Program, Oakland, California
| | - Erin Parker
- California Emerging Infections Program, Oakland, California
| | | | - James I Meek
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut
| | - Danyel Olson
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, Connecticut
| | - Monica M Farley
- Department of Medicine, Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Andrew Revis
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Stacy Holzbauer
- Minnesota Department of Health, Saint Paul, Minnesota
- Division of State and Local Readiness, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maria Bye
- Minnesota Department of Health, Saint Paul, Minnesota
| | - Lucy Wilson
- Maryland Department of Health, Baltimore, Maryland
| | | | - Erin C Phipps
- New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, New Mexico
| | - Rebecca Pierce
- Acute and Communicable Disease Prevention, Oregon Health Authority, Portland, Oregon
| | - Valerie L S Ocampo
- Acute and Communicable Disease Prevention, Oregon Health Authority, Portland, Oregon
| | | | - Miranda Smith
- Tennessee Department of Health, Nashville, Tennessee
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alice Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
12
|
Guh A, Hatfield K, Winston LG, Martin B, Johnston H, Brousseau G, Farley MM, Wilson LE, Perlmutter R, Phipps EC, Dumyati G, Nelson D, Hatwar T, Kainer MA, McDonald LC. 490. Comparison of Clostridium difficile Infection Outcomes by Diagnostic Testing Method. Open Forum Infect Dis 2018. [PMCID: PMC6253298 DOI: 10.1093/ofid/ofy210.499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background US laboratories are increasingly using nucleic acid amplification tests (NAAT) to diagnose Clostridium difficile infection (CDI) due to their increased sensitivity over toxin enzyme immunoassays (EIA), but NAATs may be more likely than toxin EIAs to detect colonization rather than true disease. Limited data indicate patients positive by toxin EIA (toxin+) have worse outcomes than those positive by NAAT (NAAT+) only, suggesting toxin EIA detects true infection more often than NAAT. We used multisite CDI surveillance data from the Centers for Disease Control and Prevention’s Emerging Infections Program to compare clinical course and outcomes between toxin+ and NAAT+ only patients. Methods A case was defined as a positive C. difficile test in a person ≥1 year old with no positive tests in the prior 8 weeks. Cases detected during 2014–2015 by a testing algorithm using toxin EIA and NAAT were classified as toxin+ or NAAT+ only. Medical charts were reviewed. Death data were obtained from state death registries. Multivariable logistic regression models were used to compare CDI recurrence and 90-day mortality between the two groups, adjusting for age, sex, race, Charlson comorbidity index, and receipt of oral vancomycin. For the outcome of recurrence, we also adjusted for history of CDI in the prior 6 months. Results Of 4,878 cases, 2160 (44%) were toxin+ and 2,718 (56%) were NAAT+ only. Toxin+ cases were more likely than NAAT+ only cases to be ≥65 years old (48% vs. 38%; P < 0.0001), have white blood cells ≥15,000/µL (483/1,539 [31%] vs. 423/1,978 [21%]; P < 0.0001), and have received oral vancomycin ≤3 days of diagnosis (32% vs. 29%; P = 0.03). Comparing toxin+ to NAAT+ only cases, 21% vs. 11% had a recurrence (P < 0.0001), of which 71% vs. 33% had a toxin+ recurrence (P < 0.0001), and 10% vs. 9% died ≤90 days of diagnosis (P = 0.12). In multivariable analysis, a toxin+ result was associated with recurrence (adjusted odds ratio [aOR]: 1.89, 95% CI: 1.61–2.22) but not with 90-day mortality (aOR: 0.99; 95% CI: 0.81–1.22). Conclusion Toxin+ CDI is more severe by some markers and more likely to recur as toxin+. However, there was no difference in adjusted mortality, which may reflect an effect on mortality in NAAT+ only cases from mild CDI, receipt of unnecessary CDI treatment, or other factors. Disclosures G. Dumyati, Seres: Scientific Advisor, Consulting fee.
Collapse
Affiliation(s)
- Alice Guh
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kelly Hatfield
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa G Winston
- Medicine, University of California, San Francisco and Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | | | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Geoff Brousseau
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Monica M Farley
- Department of Medicine, Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | | | | | - Erin C Phipps
- New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, New Mexico
| | - Ghinwa Dumyati
- NY Emerging Infections Program, Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York
| | - Deborah Nelson
- NY Emerging Infections Program, Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York
| | - Trupti Hatwar
- NY Emerging Infections Program, Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York
| | - Marion A Kainer
- Communicable and Environmental Diseases and Emergency Preparedness, Tennessee Department of Public Health, Nashville, Tennessee
| | | |
Collapse
|
13
|
Vaisman A, Chambers HF, Winston LG, Kazi D. 1788. Cost-Effectiveness of Penicillin Skin Testing Among Patients With Methicillin-Sensitive Staphylococcus aureus Bacteremia and Reported Penicillin Allergy. Open Forum Infect Dis 2018. [PMCID: PMC6253399 DOI: 10.1093/ofid/ofy210.1444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Methicillin sensitive Staphylococcus aureus (MSSA) bacteremia is a highly lethal infection; first-line therapy with a β-lactam, commonly cefazolin, provides a significant mortality benefit over the second-line therapy, vancomycin, which is often used in patients reporting β-lactam allergy. Methods We designed a simulation model of inpatients aged 55–75 years with MSSA bacteremia and a self-reported history of β-lactam allergy. The model adopted a US health-system perspective, a lifetime horizon, and a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY). We compared routine care (vancomycin), history screening (questionnaire assessing anaphylaxis history), and bedside penicillin skin testing. Incremental cost-effectiveness ratio (ICER) was measured using 2017 US dollars per QALY. Baseline co-morbid states (diabetes, malignancy, and end-stage renal disease [ESRD] requiring dialysis) were also modeled. Future costs and benefits were discounted at 3% per year. Results Among patients with MSSA bacteremia and a self-reported penicillin allergy, skin testing produced the best clinical outcomes and was cost-effective relative to history screening, generating 0.51 additional QALYs at an ICER of $22,062 per QALY gained. Among patients with diabetes, malignancy, or ESRD, the ICER for skin testing relative to history screening increased to $30,830–$127,182, reflecting the overall lower life expectancy and high annual survivor healthcare cost in these higher risk groups. Results were robust to wide variations in the cost and diagnostic performance of skin testing: in sensitivity analyses, skin testing remained the optimal strategy when cost was <$5600, specificity >60%, and sensitivity >10%. Conclusion Among adults with MSSA bacteremia and a self-reported β-lactam allergy, skin testing is cost-effective relative to history screening and routine care at conventional willingness-to-pay thresholds and should be widely adopted given the mortality benefit of β-lactams over alternate antibiotics in MSSA bacteremia. ![]()
![]()
Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
- Alon Vaisman
- Medicine, University of Toronto, Toronto, ON, Canada
| | - Henry F Chambers
- Clinical Research Services, University of California San Francisco, Clinical and Translational Sciences Institute, San Francisco, California
| | - Lisa G Winston
- Medicine, University of California, San Francisco and Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Dhruv Kazi
- Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California
| |
Collapse
|
14
|
Guh AY, Mu Y, Baggs J, Winston LG, Bamberg W, Lyons C, Farley MM, Wilson LE, Holzbauer SM, Phipps EC, Beldavs ZG, Kainer MA, Karlsson M, Gerding DN, Dumyati G. Trends in incidence of long-term-care facility onset Clostridium difficile infections in 10 US geographic locations during 2011-2015. Am J Infect Control 2018; 46:840-842. [PMID: 29329918 DOI: 10.1016/j.ajic.2017.11.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 01/01/2023]
Abstract
During 2011-2015, the adjusted long-term-care facility onset Clostridium difficile infection incidence rate in persons aged ≥65 years decreased annually by 17.45% (95% confidence interval, 14.53%-20.43%) across 10 US sites. A concomitant decline in inpatient fluoroquinolone use and the C difficile epidemic strain NAP1/027 among persons aged ≥65 years may have contributed to the decrease in long-term-care facility-onset C difficile infection incidence rate.
Collapse
Affiliation(s)
- Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Yi Mu
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - James Baggs
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lisa G Winston
- School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Wendy Bamberg
- Colorado Department of Public Health and Environment, Denver, CO
| | - Carol Lyons
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, CT
| | - Monica M Farley
- Department of Medicine, Emory University, Atlanta, GA; Georgia Emerging Infections Program, Decatur, GA; Atlanta Veterans Affairs Medical Center, Atlanta, GA
| | | | - Stacy M Holzbauer
- Minnesota Department of Health, St Paul, MN; Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, Atlanta, GA
| | - Erin C Phipps
- New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, NM
| | | | | | - Maria Karlsson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Dale N Gerding
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL; Edward Hines, Jr Veterans Affairs Hospital, Hines, IL
| | - Ghinwa Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, NY
| |
Collapse
|
15
|
Guh AY, Adkins SH, Li Q, Bulens SN, Farley MM, Smith Z, Holzbauer SM, Whitten T, Phipps EC, Hancock EB, Dumyati G, Concannon C, Kainer MA, Rue B, Lyons C, Olson DM, Wilson L, Perlmutter R, Winston LG, Parker E, Bamberg W, Beldavs ZG, Ocampo V, Karlsson M, Gerding DN, McDonald LC. Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study. Open Forum Infect Dis 2017; 4:ofx171. [PMID: 29732377 DOI: 10.1093/ofid/ofx171] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/08/2017] [Indexed: 12/26/2022] Open
Abstract
Background An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors. Methods We enrolled participants from 10 US sites during October 2014-March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed. Results Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure-that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13-321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01-311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77-340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76-340.05),-emergency department visit (AmOR, 17.37; 95% CI, 1.99-151.22), white race (AmOR 7.67; 95% CI, 2.34-25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20-19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24-118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27-20.79) were associated with CA-CDI. Conclusions Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed.
Collapse
Affiliation(s)
- Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan Hocevar Adkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Qunna Li
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sandra N Bulens
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monica M Farley
- Emory University Department of Medicine, Atlanta, Georgia.,Georgia Emerging Infections Program, Decatur, Georgia.,Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Zirka Smith
- Georgia Emerging Infections Program, Decatur, Georgia.,Atlanta Veterans Affairs Medical Center, Atlanta, Georgia.,Atlanta Research and Education Foundation, Decatur, Georgia
| | - Stacy M Holzbauer
- Minnesota Department of Health, St Paul, Minnesota.,Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tory Whitten
- Minnesota Department of Health, St Paul, Minnesota
| | - Erin C Phipps
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Emily B Hancock
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Ghinwa Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York
| | - Cathleen Concannon
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York
| | | | - Brenda Rue
- Tennessee Department of Health, Nashville, Tennessee
| | - Carol Lyons
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Danyel M Olson
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, Maryland
| | | | - Lisa G Winston
- University of California, San Francisco, School of Medicine, San Francisco, California
| | - Erin Parker
- California Emerging Infections Program, Oakland, California
| | - Wendy Bamberg
- Colorado Department of Public Health and Environment, Denver, Colorado
| | | | | | - Maria Karlsson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dale N Gerding
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois.,Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
16
|
Vaisman A, Jula M, Wagner J, Winston LG. Association Between Hospital-Onset Clostridium difficile infection and Admission to a Multi-Bed Room: A Case–control Study. Open Forum Infect Dis 2017. [PMCID: PMC5631532 DOI: 10.1093/ofid/ofx163.1000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Few studies have directly examined the link between assignment to a multi-bed vs. single-bed room and the risk for hospital onset C. difficileinfection (HO-CDI). Therefore, in this case–control study, we investigated whether assignment to a single-bed room reduced the risk of HO-CDI in adult inpatients on medical/surgical floors. Methods Consecutive cases of HO-CDI, defined as adult patients admitted to San Francisco General Hospital with a new positive C. difficile stool test >72 hours after admission, were identified for the period between January 1, 2010 to December 31, 2015. Patients who first tested positive for C. difficilein the ICU or who had a history of CDI within the last 12 months were excluded. Controls were selected from the general medical/surgical inpatient population using incidence density sampling and matched to cases on the basis of admission unit and length of admission. A multi-bed room was defined as any room with one or more roommates. A multivariate cox proportional hazard model was used to estimate the relationship between room assignment (single vs. multi-bed) and development of HO-CDI. Variables included in the model, on the basis of a directed acyclic graph, were length of admission, HIV infection, and age. Results 184 cases and 373 controls were identified during the study period. The median ages of cases and controls were 60 years and 56 years, and mean Charlson comorbidity scores were 3.8 and 3.7, respectively. The hazard ratio for the development HO-CDI associated with multi-bed room exposure was 2.32 (P = 0.03) with a 95% CI for the hazard ratio of 1.05 to 5.17. Conclusion In this study, assignment of patients to multi-bed rooms on general medical and surgical wards was associated with an increased hazard for the development of HO-CDI. This finding, especially if confirmed in other institutions, could have implications for patient room assignment and hospital design. Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
- Alon Vaisman
- Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Michael Jula
- Infection Prevention and Control, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Jessica Wagner
- Infection Prevention and Control, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Lisa G Winston
- Medicine, University of California, San Francisco and Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| |
Collapse
|
17
|
Skrobarcek K, Mu Y, Winston LG, Brousseau G, Lyons C, Farley M, Perlmutter R, Holzbauer S, Phipps EC, Dumyati G, Beldavs ZG, Kainer M, Guh A. Socioeconomic Status Factors Associated with Increased Incidence of Community-Associated Clostridium difficile Infection. Open Forum Infect Dis 2017. [PMCID: PMC5630861 DOI: 10.1093/ofid/ofx163.944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Traditionally a hospital-acquired pathogen, Clostridium difficile is increasingly recognized as an important cause of diarrhea in community settings. Health disparities in C. difficileinfection (CDI) have been reported, but little is known about the social determinants of health that influence community-associated (CA) CDI incidence. We sought to identify socioeconomic status (SES) factors associated with increased CA-CDI incidence. Methods Population-based CDI surveillance is conducted in 35 U.S. counties through the Centers for Disease Control and Prevention’s Emerging Infections Program. A CA-CDI case is defined as a positive C. difficile stool specimen collected as an outpatient or within three days of hospitalization in a person aged ≥ 1 year who did not have a positive test in the prior 8 weeks or an overnight stay in a healthcare facility in the prior 12 weeks. ArcGIS software was used to geocode 2014–2015 CA-CDI case addresses to a 2010 census tract (CT). Incidence rate was calculated using 2010 Census population denominators. CT-level SES factors were obtained from the 2011–2015 American Community Survey 5-year estimates and divided into deciles. To account for CT-level clustering effects, separate generalized linear mixed models with negative binomial distribution were used to evaluate the association between each SES factor and CA-CDI incidence, adjusted by age, sex and race. Results Of 9686 CA-CDI cases, 9417 (97%) had addresses geocoded to a CT; of these, 62% were female, 82% were white, and 35% were aged ≥65 years. Annual CA-CDI incidence was 42.9 per 100,000 persons. After adjusting for age, sex and race, CT-level SES factors significantly associated with increased CA-CDI incidence included living under the poverty level (rate ratio [RR] 1.12; 95% confidence interval [CI] 1.09–1.53), crowding in homes (RR 1.11; 95% CI 1.01–1.21), low education (RR 1.11; 95% CI 1.07–1.15), low income (RR 1.15; 95% CI 1.12–1.17), having public health insurance (RR 1.21; 95% CI 1.18–1.24), receiving public assistance income (RR 1.69; 95% CI 1.55–1.84), and unemployment (RR 1.14; 95% CI 1.07–1.22). Conclusion Areas with lower SES have modestly increased CA-CDI incidence. Understanding the mechanisms by which SES factors impact CA-CDI incidence could help guide prevention efforts in these higher-risk areas. Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
- Kimberly Skrobarcek
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yi Mu
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa G Winston
- Medicine, University of California, San Francisco and Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Geoff Brousseau
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Carol Lyons
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Monica Farley
- Department of Medicine, Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia
| | | | | | - Erin C Phipps
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Ghinwa Dumyati
- New York Emerging Infections Program at the University of Rochester Medical Center, Rochester, New York
| | | | - Marion Kainer
- Tennessee Department of Health, Nashville, Tennessee
| | - Alice Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
18
|
Novosad S, Winston LG, Johnston H, Badolato E, Lyons C, Farley M, Revis A, Wilson L, Perlmutter R, Holzbauer SM, Whitten T, Phipps EC, Dumyati G, Beldaversus ZG, Ocampo VL, Kainer M, Davis CM, Barnes J, Gerding D, Guh A. Treatment of Clostridium difficile Infection in 10 US Geographical Locations, 2013–2014. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Shannon Novosad
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa G. Winston
- University of California, San Francisco, School of Medicine, Department of Medicine, San Francisco, California
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado
| | | | - Carol Lyons
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Monica Farley
- Department of Medicine, Emory University School of Medicine and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Andrew Revis
- Georgia Emerging Infections Program, Research and Education Foundation, Decatur, Georgia
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, Maryland
| | | | | | - Tory Whitten
- Infectious Disease Epidemiology, Prevention, and Control Division, Minnesota Department of Health, St. Paul, Minnesota
| | - Erin C. Phipps
- New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Ghinwa Dumyati
- University of Rochester Medical Center, Rochester, New York
| | | | | | - Marion Kainer
- Tennessee Department of Health, Nashville, Tennessee
| | | | - Jamie Barnes
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dale Gerding
- Hines Veterans Affairs Hospital, Hines, Illinois
| | - Alice Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
19
|
Hunter JC, Mu Y, Dumyati GK, Farley MM, Winston LG, Johnston HL, Meek JI, Perlmutter R, Holzbauer SM, Beldavs ZG, Phipps EC, Dunn JR, Cohen JA, Avillan J, Stone ND, Gerding DN, McDonald LC, Lessa FC. Burden of Nursing Home-Onset Clostridium difficile Infection in the United States: Estimates of Incidence and Patient Outcomes. Open Forum Infect Dis 2016; 3:ofv196. [PMID: 26798767 PMCID: PMC4719744 DOI: 10.1093/ofid/ofv196] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/07/2015] [Indexed: 01/05/2023] Open
Abstract
Background. Approximately 4 million Americans receive nursing home (NH) care annually. Nursing home residents commonly have risk factors for Clostridium difficile infection (CDI), including advanced age and antibiotic exposures. We estimated national incidence of NH-onset (NHO) CDI and patient outcomes. Methods. We identified NHO-CDI cases from population-based surveillance of 10 geographic areas in the United States. Cases were defined by C difficile-positive stool collected in an NH (or from NH residents in outpatient settings or ≤3 days after hospital admission) without a positive stool in the prior 8 weeks. Medical records were reviewed on a sample of cases. Incidence was estimated using regression models accounting for age and laboratory testing method; sampling weights were applied to estimate hospitalizations, recurrences, and deaths. Results. A total of 3503 NHO-CDI cases were identified. Among 262 sampled cases, median age was 82 years, 76% received antibiotics in the 12 weeks prior to the C difficile-positive specimen, and 57% were discharged from a hospital in the month before specimen collection. After adjusting for age and testing method, the 2012 national estimate for NHO-CDI incidence was 112 800 cases (95% confidence interval [CI], 93 400-131 800); 31 400 (28%) were hospitalized within 7 days after a positive specimen (95% CI, 25 500-37 300), 20 900 (19%) recurred within 14-60 days (95% CI, 14 600-27 100), and 8700 (8%) died within 30 days (95% CI, 6600-10 700). Conclusions. Nursing home onset CDI is associated with substantial morbidity and mortality. Strategies focused on infection prevention in NHs and appropriate antibiotic use in both NHs and acute care settings may decrease the burden of NHO CDI.
Collapse
Affiliation(s)
- Jennifer C Hunter
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases; Division of Scientific Education and Professional Development, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yi Mu
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
| | | | - Monica M Farley
- Department of Medicine, Emory University School of Medicine; Atlanta Veterans Affairs Medical Center, Georgia
| | - Lisa G Winston
- Department of Medicine , University of California, San Francisco School of Medicine
| | | | - James I Meek
- Connecticut Emerging Infections Program , Yale School of Public Health , New Haven
| | | | - Stacy M Holzbauer
- Minnesota Department of Health, St. Paul; Division of State and Local Readiness, Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response, Atlanta, Georgia
| | | | - Erin C Phipps
- New Mexico Emerging Infections Program , University of New Mexico , Albuquerque
| | | | - Jessica A Cohen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases; Atlanta Research and Education Foundation, Georgia
| | - Johannetsy Avillan
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
| | - Nimalie D Stone
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
| | - Dale N Gerding
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
| | - Fernanda C Lessa
- Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
| |
Collapse
|
20
|
Dantes R, Mu Y, Hicks LA, Cohen J, Bamberg W, Beldavs ZG, Dumyati G, Farley MM, Holzbauer S, Meek J, Phipps E, Wilson L, Winston LG, McDonald LC, Lessa FC. Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection. Open Forum Infect Dis 2015; 2:ofv113. [PMID: 26509182 PMCID: PMC4551478 DOI: 10.1093/ofid/ofv113] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/03/2015] [Indexed: 01/21/2023] Open
Abstract
A modest, 10% reduction in outpatient antibiotic prescribing among U.S. adults
could result in a substantial 17% reduction in Clostridium
difficile infections that originate in the community. Background. Antibiotic use predisposes patients to
Clostridium difficile infections (CDI), and approximately
32% of these infections are community-associated (CA) CDI. The
population-level impact of antibiotic use on adult CA-CDI rates is not well
described. Methods. We used 2011 active population- and
laboratory-based surveillance data from 9 US geographic locations to identify adult
CA-CDI cases, defined as C difficile-positive stool specimens (by
toxin or molecular assay) collected from outpatients or from patients ≤3 days
after hospital admission. All patients were surveillance area residents and aged
≥20 years with no positive test ≤8 weeks prior and no overnight stay in a
healthcare facility ≤12 weeks prior. Outpatient oral antibiotic prescriptions
dispensed in 2010 were obtained from the IMS Health Xponent database. Regression
models examined the association between outpatient antibiotic prescribing and adult
CA-CDI rates. Methods. Healthcare providers prescribed 5.2
million courses of antibiotics among adults in the surveillance population in 2010,
for an average of 0.73 per person. Across surveillance sites, antibiotic prescription
rates (0.50–0.88 prescriptions per capita) and unadjusted CA-CDI rates
(40.7–139.3 cases per 100 000 persons) varied. In regression modeling, reducing
antibiotic prescribing rates by 10% among persons ≥20 years old was
associated with a 17% (95% confidence interval,
6.0%–26.3%; P = .032) decrease in CA-CDI
rates after adjusting for age, gender, race, and type of diagnostic assay. Reductions
in prescribing penicillins and amoxicillin/clavulanic acid were associated with the
greatest decreases in CA-CDI rates. Conclusions and Relevance. Community-associated
CDI prevention should include reducing unnecessary outpatient antibiotic use. A
modest reduction of 10% in outpatient antibiotic prescribing can have a
disproportionate impact on reducing CA-CDI rates.
Collapse
Affiliation(s)
| | - Yi Mu
- Centers for Disease Control and Prevention , Atlanta
| | - Lauri A Hicks
- Centers for Disease Control and Prevention , Atlanta
| | - Jessica Cohen
- Centers for Disease Control and Prevention , Atlanta ; Atlanta Research and Education Foundation, Georgia
| | - Wendy Bamberg
- Colorado Department of Public Health and Environment, Denver
| | | | | | - Monica M Farley
- Emory University , Atlanta ; Atlanta Veterans Affairs Medical Center , Georgia
| | | | - James Meek
- Connecticut Emerging Infections Program , New Haven
| | | | - Lucy Wilson
- Maryland Emerging Infections Program Baltimore ; Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Lisa G Winston
- University of California , San Francisco ; San Francisco General Hospital , California
| | | | | |
Collapse
|
21
|
|
22
|
Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, Farley MM, Holzbauer SM, Meek JI, Phipps EC, Wilson LE, Winston LG, Cohen JA, Limbago BM, Fridkin SK, Gerding DN, McDonald LC. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015; 372:825-34. [PMID: 25714160 PMCID: PMC10966662 DOI: 10.1056/nejmoa1408913] [Citation(s) in RCA: 1848] [Impact Index Per Article: 205.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The magnitude and scope of Clostridium difficile infection in the United States continue to evolve. METHODS In 2011, we performed active population- and laboratory-based surveillance across 10 geographic areas in the United States to identify cases of C. difficile infection (stool specimens positive for C. difficile on either toxin or molecular assay in residents ≥ 1 year of age). Cases were classified as community-associated or health care-associated. In a sample of cases of C. difficile infection, specimens were cultured and isolates underwent molecular typing. We used regression models to calculate estimates of national incidence and total number of infections, first recurrences, and deaths within 30 days after the diagnosis of C. difficile infection. RESULTS A total of 15,461 cases of C. difficile infection were identified in the 10 geographic areas; 65.8% were health care-associated, but only 24.2% had onset during hospitalization. After adjustment for predictors of disease incidence, the estimated number of incident C. difficile infections in the United States was 453,000 (95% confidence interval [CI], 397,100 to 508,500). The incidence was estimated to be higher among females (rate ratio, 1.26; 95% CI, 1.25 to 1.27), whites (rate ratio, 1.72; 95% CI, 1.56 to 2.0), and persons 65 years of age or older (rate ratio, 8.65; 95% CI, 8.16 to 9.31). The estimated number of first recurrences of C. difficile infection was 83,000 (95% CI, 57,000 to 108,900), and the estimated number of deaths was 29,300 (95% CI, 16,500 to 42,100). The North American pulsed-field gel electrophoresis type 1 (NAP1) strain was more prevalent among health care-associated infections than among community-associated infections (30.7% vs. 18.8%, P<0.001). CONCLUSIONS C. difficile was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011. (Funded by the Centers for Disease Control and Prevention.).
Collapse
|
23
|
Winston LG, Felt SC, Huang WH, Chambers HF. Introduction of a Waterless Hand Gel Was Associated With a Reduced Rate of Ventilator-Associated Pneumonia in a Surgical Intensive Care Unit. Infect Control Hosp Epidemiol 2015; 25:1015-6. [PMID: 15636285 DOI: 10.1086/503494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
24
|
Hunter JC, Mu Y, Dumyati GK, Farley MM, Winston LG, Johnston HL, Meek JI, Wilson LE, Stacy M, Beldavs ZG, Phipps EC, Dunn JR, Cohen JA, Stone ND, Clifford Mcdonald L, Lessa FC. 524National estimates of incidence, recurrence, hospitalization, and death of nursing home-onset Clostridium difficile infections — United States, 2012. Open Forum Infect Dis 2014. [PMCID: PMC5782210 DOI: 10.1093/ofid/ofu051.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jennifer C. Hunter
- Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion, Atlanta, GA
- Centers for Disease Control and Prevention, Division of Scientific Education and Professional Development, Epidemic Intelligence Service, Atlanta, GA
| | - Yi Mu
- Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion, Atlanta, GA
| | | | - Monica M. Farley
- Emory University School of Medicine, Atlanta, GA
- Medicine/Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Atlanta Veterans Affairs Medical Center, Decatur, GA
| | - Lisa G. Winston
- University of California, San Francisco, School of Medicine, Department of Medicine, San Francisco, CA
| | | | - James I. Meek
- Connecticut Emerging Infections Program, Yale School of Public Health, New Haven, CT
| | - Lucy E. Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, MD
| | - M Stacy
- Minnesota Department of Health, St. Paul, MN
- 11Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response, Career Epidemiology Field Office Program, St. Paul, MN
| | - Zintars G. Beldavs
- Acute & Communicable Disease Prevention, Oregon Health Authority, Portland, OR
| | | | | | - Jessica a. Cohen
- Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion, Atlanta, GA
- Atlanta Research and Education Foundation, Atlanta, GA
| | - Nimalie D. Stone
- Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion, Atlanta, GA
| | - L. Clifford Mcdonald
- Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion, Atlanta, GA
| | - Fernanda C. Lessa
- Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion, Atlanta, GA
| |
Collapse
|
25
|
Lessa FC, Mu Y, Winston LG, Dumyati GK, Farley MM, Beldavs ZG, Kast K, Holzbauer SM, Meek JI, Cohen J, McDonald LC, Fridkin SK. Determinants of Clostridium difficile Infection Incidence Across Diverse United States Geographic Locations. Open Forum Infect Dis 2014; 1:ofu048. [PMID: 25734120 PMCID: PMC4281776 DOI: 10.1093/ofid/ofu048] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 06/05/2014] [Indexed: 12/12/2022] Open
Abstract
Nucleic acid amplification test, age, race and sex are associated with increased community-associated Clostridium difficile infection (CDI) incidence, while age and number of inpatient-days are associated with increased healthcare-associated CDI incidence. Comparison of CDI incidence across regions should account for these factors. Background Clostridium difficile infection (CDI) is no longer restricted to hospital settings, and population-based incidence measures are needed. Understanding the determinants of CDI incidence will allow for more meaningful comparisons of rates and accurate national estimates. Methods Data from active population- and laboratory-based CDI surveillance in 7 US states were used to identify CDI cases (ie, residents with positive C difficile stool specimen without a positive test in the prior 8 weeks). Cases were classified as community-associated (CA) if stool was collected as outpatients or ≤3 days of admission and no overnight healthcare facility stay in the past 12 weeks; otherwise, cases were classified as healthcare-associated (HA). Two regression models, one for CA-CDI and another for HA-CDI, were built to evaluate predictors of high CDI incidence. Site-specific incidence was adjusted based on the regression models. Results Of 10 062 cases identified, 32% were CA. Crude incidence varied by geographic area; CA-CDI ranged from 28.2 to 79.1/100 000 and HA-CDI ranged from 45.7 to 155.9/100 000. Independent predictors of higher CA-CDI incidence were older age, white race, female gender, and nucleic acid amplification test (NAAT) use. For HA-CDI, older age and a greater number of inpatient-days were predictors. After adjusting for relevant predictors, the range of incidence narrowed greatly; CA-CDI rates ranged from 30.7 to 41.3/100 000 and HA-CDI rates ranged from 58.5 to 94.8/100 000. Conclusions Differences in CDI incidence across geographic areas can be partially explained by differences in NAAT use, age, race, sex, and inpatient-days. Variation in antimicrobial use may contribute to the remaining differences in incidence.
Collapse
Affiliation(s)
- Fernanda C Lessa
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases , Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Yi Mu
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases , Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Lisa G Winston
- Division of Infectious Diseases , University of California, San Francisco School of Medicine
| | - Ghinwa K Dumyati
- Division of Infectious Diseases , University of Rochester Medical Center , New York
| | - Monica M Farley
- Division of Infectious Diseases , Emory University School of Medicine , Atlanta, Georgia ; Atlanta Veterans Affairs Medical Center , Georgia
| | | | - Kelly Kast
- Colorado Department of Public Health and Environment, Denver
| | - Stacy M Holzbauer
- Centers for Disease Control and Prevention Epidemiology Field Officer Assigned to Minnesota Department of Health, St. Paul, Minnesota
| | - James I Meek
- Emerging Infections Program , Yale University School of Public Health , New Haven, Connecticut
| | - Jessica Cohen
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases , Centers for Disease Control and Prevention , Atlanta, Georgia ; Atlanta Research and Education Foundation , Georgia
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases , Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Scott K Fridkin
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases , Centers for Disease Control and Prevention , Atlanta, Georgia
| |
Collapse
|
26
|
Wendt JM, Cohen JA, Mu Y, Dumyati GK, Dunn JR, Holzbauer SM, Winston LG, Johnston HL, Meek JI, Farley MM, Wilson LE, Phipps EC, Beldavs ZG, Gerding DN, McDonald LC, Gould CV, Lessa FC. Clostridium difficile infection among children across diverse US geographic locations. Pediatrics 2014; 133:651-8. [PMID: 24590748 PMCID: PMC10932476 DOI: 10.1542/peds.2013-3049] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Little is known about the epidemiology of Clostridium difficile infection (CDI) among children, particularly children ≤3 years of age in whom colonization is common but pathogenicity uncertain. We sought to describe pediatric CDI incidence, clinical presentation, and outcomes across age groups. METHODS Data from an active population- and laboratory-based CDI surveillance in 10 US geographic areas during 2010-2011 were used to identify cases (ie, residents with C difficile-positive stool without a positive test in the previous 8 weeks). Community-associated (CA) cases had stool collected as outpatients or ≤3 days after hospital admission and no overnight health care facility stay in the previous 12 weeks. A convenience sample of CA cases were interviewed. Demographic, exposure, and clinical data for cases aged 1 to 17 years were compared across 4 age groups: 1 year, 2 to 3 years, 4 to 9 years, and 10 to 17 years. RESULTS Of 944 pediatric CDI cases identified, 71% were CA. CDI incidence per 100,000 children was highest among 1-year-old (66.3) and white (23.9) cases. The proportion of cases with documented diarrhea (72%) or severe disease (8%) was similar across age groups; no cases died. Among the 84 cases interviewed who reported diarrhea on the day of stool collection, 73% received antibiotics during the previous 12 weeks. CONCLUSIONS Similar disease severity across age groups suggests an etiologic role for C difficile in the high rates of CDI observed in younger children. Prevention efforts to reduce unnecessary antimicrobial use among young children in outpatient settings should be prioritized.
Collapse
Affiliation(s)
- Joyanna M. Wendt
- Division of Healthcare Quality Promotion, National Center
for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and
Prevention, Atlanta, Georgia
- Epidemic Intelligence Service, Office of Surveillance
Epidemiology and Laboratory Services, Centers for Disease Control and Prevention,
Atlanta, Georgia
| | - Jessica A. Cohen
- Division of Healthcare Quality Promotion, National Center
for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and
Prevention, Atlanta, Georgia
- Atlanta Research and Education Foundation, Atlanta,
Georgia
| | - Yi Mu
- Division of Healthcare Quality Promotion, National Center
for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | - Ghinwa K. Dumyati
- Department of Medicine, University of Rochester Medical
Center, Rochester, New York
| | - John R. Dunn
- Tennessee Department of Health, Nashville, Tennessee
| | - Stacy M. Holzbauer
- Office of Public Health Preparedness and Response, Career
Epidemiology Field Office Program, Centers for Disease Control and Prevention,
Atlanta, Georgia
- Department of Medicine, Minnesota Department of Health, St
Paul, Minnesota
| | - Lisa G. Winston
- University of California, San Francisco, School of
Medicine, San Francisco, California
| | - Helen L. Johnston
- Colorado Department of Public Health and Environment,
Denver, Colorado
| | - James I. Meek
- Yale School of Public Health, Connecticut Emerging
Infections Program, New Haven, Connecticut
| | - Monica M. Farley
- Department of Medicine, Emory University School of
Medicine, Atlanta, Georgia
- Atlanta Veterans Affairs Medical Center, Atlanta,
Georgia
| | - Lucy E. Wilson
- Maryland Department of Health and Mental Hygiene,
Baltimore, Maryland
| | - Erin C. Phipps
- Emerging Infections Program, University of New Mexico,
Albuquerque, New Mexico
| | | | - Dale N. Gerding
- Department of Medicine, Stritch School of Medicine, Loyola
University Chicago, Maywood, Illinois
- Edward Hines Jr Veterans Affairs Hospital, Hines,
Illinois
| | - L. Clifford McDonald
- Division of Healthcare Quality Promotion, National Center
for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | - Carolyn V. Gould
- Division of Healthcare Quality Promotion, National Center
for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and
Prevention, Atlanta, Georgia
| | - Fernanda C. Lessa
- Division of Healthcare Quality Promotion, National Center
for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and
Prevention, Atlanta, Georgia
| |
Collapse
|
27
|
See I, Mu Y, Cohen J, Beldavs ZG, Winston LG, Dumyati G, Holzbauer S, Dunn J, Farley MM, Lyons C, Johnston H, Phipps E, Perlmutter R, Anderson L, Gerding DN, Lessa FC. NAP1 strain type predicts outcomes from Clostridium difficile infection. Clin Infect Dis 2014; 58:1394-400. [PMID: 24604900 DOI: 10.1093/cid/ciu125] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Studies are conflicting regarding the importance of the fluoroquinolone-resistant North American pulsed-field gel electrophoresis type 1 (NAP1) strain in Clostridium difficile infection (CDI) outcome. We describe strain types causing CDI and evaluate their association with patient outcomes. METHODS CDI cases were identified from population-based surveillance. Multivariate regression models were used to evaluate the associations of strain type with severe disease (ileus, toxic megacolon, or pseudomembranous colitis within 5 days; or white blood cell count ≥15 000 cells/µL within 1 day of positive test), severe outcome (intensive care unit admission after positive test, colectomy for C. difficile infection, or death within 30 days of positive test), and death within 14 days of positive test. RESULTS Strain typing results were available for 2057 cases. Severe disease occurred in 363 (17.7%) cases, severe outcome in 100 (4.9%), and death within 14 days in 56 (2.7%). The most common strain types were NAP1 (28.4%), NAP4 (10.2%), and NAP11 (9.1%). In unadjusted analysis, NAP1 was associated with greater odds of severe disease than other strains. After controlling for patient risk factors, healthcare exposure, and antibiotic use, NAP1 was associated with severe disease (adjusted odds ratio [AOR], 1.74; 95% confidence interval [CI], 1.36-2.22), severe outcome (AOR, 1.66; 95% CI, 1.09-2.54), and death within 14 days (AOR, 2.12; 95% CI, 1.22-3.68). CONCLUSIONS NAP1 was the most prevalent strain and a predictor of severe disease, severe outcome, and death. Strategies to reduce NAP1 prevalence, such as antibiotic stewardship to reduce fluoroquinolone use, might reduce CDI morbidity.
Collapse
Affiliation(s)
- Isaac See
- Division of Healthcare Quality Promotion
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Chitnis AS, Holzbauer SM, Belflower RM, Winston LG, Bamberg WM, Lyons C, Farley MM, Dumyati GK, Wilson LE, Beldavs ZG, Dunn JR, Gould LH, MacCannell DR, Gerding DN, McDonald LC, Lessa FC. Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011. JAMA Intern Med 2013; 173:1359-67. [PMID: 23780507 DOI: 10.1001/jamainternmed.2013.7056] [Citation(s) in RCA: 309] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Clostridium difficile infection (CDI) has been increasingly reported among healthy individuals in the community. Recent data suggest that community-associated CDI represents one-third of all C difficile cases. The epidemiology and potential sources of C difficile in the community are not fully understood. OBJECTIVES To determine epidemiological and clinical characteristics of community-associated CDI and to explore potential sources of C difficile acquisition in the community. DESIGN AND SETTING Active population-based and laboratory-based CDI surveillance in 8 US states. PARTICIPANTS Medical records were reviewed and interviews performed to assess outpatient, household, and food exposures among patients with community-associated CDI (ie, toxin or molecular assay positive for C difficile and no overnight stay in a health care facility within 12 weeks). Molecular characterization of C difficile isolates was performed. Outpatient health care exposure in the prior 12 weeks among patients with community-associated CDI was a priori categorized into the following 3 levels: no exposure, low-level exposure (ie, outpatient visit with physician or dentist), or high-level exposure (ie, surgery, dialysis, emergency or urgent care visit, inpatient care with no overnight stay, or health care personnel with direct patient care). MAIN OUTCOMES AND MEASURES Prevalence of outpatient health care exposure among patients with community-associated CDI and identification of potential sources of C difficile by level of outpatient health care exposure. RESULTS Of 984 patients with community-associated CDI, 353 (35.9%) did not receive antibiotics, 177 (18.0%) had no outpatient health care exposure, and 400 (40.7%) had low-level outpatient health care exposure. Thirty-one percent of patients without antibiotic exposure received proton pump inhibitors. Patients having CDI with no or low-level outpatient health care exposure were more likely to be exposed to infants younger than 1 year (P = .04) and to household members with active CDI (P = .05) compared with those having high-level outpatient health care exposure. No association between food exposure or animal exposure and level of outpatient health care exposure was observed. North American pulsed-field gel electrophoresis (NAP) 1 was the most common (21.7%) strain isolated; NAP7 and NAP8 were uncommon (6.7%). CONCLUSIONS AND RELEVANCE Most patients with community-associated CDI had recent outpatient health care exposure, and up to 36% would not be prevented by reduction of antibiotic use only. Our data support evaluation of additional strategies, including further examination of C difficile transmission in outpatient and household settings and reduction of proton pump inhibitor use.
Collapse
Affiliation(s)
- Amit S Chitnis
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Wooten DA, Winston LG. Risk factors for methicillin-resistant Staphylococcus aureus in patients with community-onset and hospital-onset pneumonia. Respir Med 2013; 107:1266-70. [PMID: 23756035 DOI: 10.1016/j.rmed.2013.05.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 04/07/2013] [Accepted: 05/03/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The risk factors for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia have not been fully characterized and are likely to be different depending on whether infection is acquired in the community or the hospital. METHODS We conducted a case-control study of 619 adults hospitalized between 2005 and 2010 with either MRSA or methicillin-sensitive S. aureus (MSSA) pneumonia. Patients with a respiratory culture within 48 h of hospitalization had community-onset pneumonia whereas patients with a culture collected after this time point had hospital-onset pneumonia. RESULTS Among patients with community-onset disease, the risk for MRSA was increased by tobacco use (OR 2.31, CI 1.23-4.31), chronic obstructive pulmonary disease (OR 3.76, CI 1.74-8.08), and recent antibiotic exposure (OR 4.87, CI 2.35-10.1) in multivariate analysis while patients with hospital-onset disease had an increased MRSA risk with tobacco use (OR 2.66, CI 1.38-5.14), illicit drug use (OR 3.52, CI 2.21-5.59), and recent antibiotic exposure (OR 2.04, CI 3.54-13.01). Hospitalization within the prior three months was associated with decreased risk (OR 0.64, CI 0.46-0.89) in multivariate analysis. CONCLUSIONS This study suggests there are common and distinct risk factors for MRSA pneumonia based on location of onset. The decreased risk for MRSA pneumonia associated with recent hospitalization is unexpected and warrants further investigation. SUMMARY This case-control study showed that there are common and distinct risk factors associated with MRSA pneumonia depending on whether the infection onset is in the hospital or in the community. Recent hospitalization was unexpectedly shown to be associated with decreased risk for MRSA pneumonia and warrants further investigation.
Collapse
Affiliation(s)
- D A Wooten
- University of California, San Francisco, Department of Internal Medicine, USA.
| | | |
Collapse
|
30
|
Doernberg SB, Winston LG, Deck DH, Chambers HF. Does doxycycline protect against development of Clostridium difficile infection? Clin Infect Dis 2012; 55:615-20. [PMID: 22563022 DOI: 10.1093/cid/cis457] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Receipt of antibiotics is a major risk factor for Clostridium difficile infection (CDI). Doxycycline has been associated with a lower risk for CDI than other antibiotics. We investigated whether doxycycline protected against development of CDI in hospitalized patients receiving ceftriaxone, a high-risk antibiotic for CDI. METHODS We studied adults admitted to an academic county hospital between 1 June 2005 and 31 December 2010 who received ceftriaxone to determine whether the additional receipt of doxycycline decreased the risk of CDI. Patients were followed from first administration of ceftriaxone to occurrence of CDI or administrative closure 30 days later. RESULTS Two thousand three hundred five unique patients comprising 2734 hospitalizations were studied. Overall, 43 patients developed CDI within 30 days of ceftriaxone receipt, an incidence of 5.60 cases per 10 000 patient-days. The incidence of CDI was 1.67 cases per 10 000 patient-days in those receiving doxycycline, compared to 8.11 per 10 000 patient-days in those who did not receive doxycycline. In a multivariable model adjusted for age, gender, race, comorbidities, hospital duration, pneumonia diagnosis, surgical admission, and duration of ceftriaxone and other antibiotics, for each day of doxycycline receipt the rate of CDI was 27% lower than a patient who did not receive doxycycline (hazard ratio, 0.73; 95% confidence interval, .56-.96). CONCLUSIONS In this cohort of patients receiving ceftriaxone, doxycycline was associated with lower risk of CDI. Guidelines recommend this combination as a second-line regimen for some patients with community-acquired pneumonia (CAP). Further clinical studies would help define whether doxycycline-containing regimens should be a preferred therapy for CAP.
Collapse
Affiliation(s)
- Sarah B Doernberg
- Department of Internal Medicine, Division of Infectious Diseases, University of California, San Francisco, CA 94110, USA.
| | | | | | | |
Collapse
|
31
|
Doernberg SB, Winston LG. Risk factors for acquisition of extended-spectrum β-lactamase-producing Escherichia coli in an urban county hospital. Am J Infect Control 2012; 40:123-7. [PMID: 21775020 DOI: 10.1016/j.ajic.2011.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 04/01/2011] [Accepted: 04/05/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Better characterization of risk factors for extended-spectrum β-lactamase (ESBL)-producing bacteria is important for prevention, control, and treatment. This study aimed to identify risk factors for ESBL-producing Escherichia coli in a population of patients at an acute care urban teaching hospital. METHODS A matched case-control study was performed. Cases comprised adults with ESBL E coli isolated from any source and matched with controls on year of hospitalization. One control group included patients with non-ESBL E coli, and a second control group consisted of patients with another resistant bacterium with well-characterized risk factors, Pseudomonas aeruginosa. RESULTS There were 93 subjects in each group. Risk factors associated with ESBL cases compared with both control groups in a univariate model included sex, age, comorbidity, health care facility residence, recent hospitalization, and hemodialysis. In multivariate analysis, only Charlson comorbidity score remained significant between the cases and both control groups. Recent receipt of antibiotics was a risk factor for ESBL E coli versus non-ESBL E coli but not versus P aeruginosa. CONCLUSIONS Underlying comorbid illness appears to be a robust risk factor for acquisition of ESBL-producing E coli. Antibiotic use is a less clear risk factor and may be a surrogate for health care exposure in general.
Collapse
|
32
|
Chew KW, Yen IH, Li JZ, Winston LG. Predictors of pneumonia severity in HIV-infected adults admitted to an Urban public hospital. AIDS Patient Care STDS 2011; 25:273-7. [PMID: 21488749 DOI: 10.1089/apc.2010.0365] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Data on outcomes of community-acquired pneumonia (CAP) in the HIV-infected population are mixed and the perception of worse outcomes in HIV may lead to excess hospitalization. We retrospectively evaluated the utility of the Pneumonia Severity Index, or PORT score, as a prediction rule for mortality in 102 HIV-infected adults hospitalized at an urban public hospital with CAP. Primary outcome was survival at 30 days. Secondary outcomes included survival on discharge, intensive care unit (ICU) admission, length of stay, and readmission within 30 days. The cohort was predominantly male (70%) with a mean age of 45.4 years (standard deviation [SD] ± 7.4). Mean CD4 cell count was 318 cells per microliter; 40 (39%) had CD4 less than 200 cells per microliter. Forty-three percent were on antiretroviral therapy at the time of admission and 31% on prophylactic antibiotics. Twelve patients had bacteremia on admission, predominantly with Streptococcus pneumoniae. Of the 46 patients with admission sputum cultures, 20 yielded an organism, most commonly Haemophilus influenzae and S. pneumoniae. Overall survival in the cohort was high, 96%. Most patients (81%) had a low PORT risk score (class I-III). PORT score predicted 30-day survival (p=0.01) and ICU admission (p=0.03), but antiretroviral use did not. In contrast to a prior study, we did not find that CD4 cell count predicted CAP outcome. Lack of stable housing was not associated with worse outcomes. The PORT score may be a valid tool to predict mortality and need for hospital admission in HIV-infected patients with CAP.
Collapse
Affiliation(s)
- Kara W. Chew
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
| | - Irene H. Yen
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Jonathan Z. Li
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa G. Winston
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California
| |
Collapse
|
33
|
Jain V, Yang MH, Kovacicova-Lezcano G, Juhle LS, Bolger AF, Winston LG. Infective endocarditis in an urban medical center: association of individual drugs with valvular involvement. J Infect 2008; 57:132-8. [PMID: 18597851 DOI: 10.1016/j.jinf.2008.05.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2008] [Revised: 05/12/2008] [Accepted: 05/14/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Injection drug users (IDUs) develop more right-sided infective endocarditis (IE) than non-IDUs, but it is not known whether this risk is specific to any particular injected drug. This study reviews the clinical characteristics of IE in an urban population and examines the association of drug type with manifestations of IE. METHODS A retrospective cohort of 247 cases of IE was analyzed. Demographic, clinical, microbiologic, and echocardiographic data were collected. RESULTS Our cohort featured a 74% IDU rate, most with heroin. Staphylococcus aureus was the most prevalent organism. S. aureus IE was more likely to occur in IDUs versus non-IDUs (OR 5.5, p<0.0001). Enterococcus faecalis IE was less likely to occur in IDUs (OR 0.21, p=0.02). Tricuspid valve (TV) IE was more likely to occur in IDUs (OR 4.37, p=0.001), while mitral valve (MV) IE occurred less commonly in IDUs (OR 0.40, p=0.005). TV IE occurred more frequently in heroin users vs. IDUs not using heroin (OR 4.03, p=0.033). CONCLUSIONS The epidemiology of IE in this cohort is different from that reported recently in other cohorts, likely due to the high prevalence of IDU. Heroin use may underlie the association between IDU and right-sided endocarditis.
Collapse
Affiliation(s)
- Vivek Jain
- Department of Internal Medicine, University of California, San Francisco; San Francisco General Hospital, San Francisco, CA, USA
| | | | | | | | | | | |
Collapse
|
34
|
Abstract
Infective endocarditis (IE) is a rare disease. Although its incidence and bacteriology have remained relatively stable in outpatient populations without injection drug use, health care-associated infections, particularly with staphylococcus, are becoming more common. Large-scale prospective clinical trials are unavailable to guide strategies for preventing IE, timing surgical intervention, and avoiding complications. We continue to rely on new data from smaller series and large observational databases to track these changes and improve care of patients. At the present time, there are several controversies regarding best practices in IE. In this review, we address the following questions: What is the future of recommendations for antibiotic prophylaxis against IE? How should we best use echocardiography in diagnosis, management and follow up of IE patients? What are the most appropriate antibiotic regimens for different patients in the face of shifting microbiology and demographics? Lastly, how should patients be selected for early surgery to avoid the complications of these infections?
Collapse
Affiliation(s)
- Lisa G Winston
- Division of Cardiology, University of California, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | | |
Collapse
|
35
|
Li JZ, Winston LG, Moore DH, Bent S. Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis. Am J Med 2007; 120:783-90. [PMID: 17765048 DOI: 10.1016/j.amjmed.2007.04.023] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2006] [Revised: 04/21/2007] [Accepted: 04/25/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE There is little consensus on the most appropriate duration of antibiotic treatment for community-acquired pneumonia. The goal of this study is to systematically review randomized controlled trials comparing short-course and extended-course antibiotic regimens for community-acquired pneumonia. METHODS We searched MEDLINE, Embase, and CENTRAL, and reviewed reference lists from 1980 through June 2006. Studies were included if they were randomized controlled trials that compared short-course (7 days or less) versus extended-course (>7 days) antibiotic monotherapy for community-acquired pneumonia in adults. The primary outcome measure was failure to achieve clinical improvement. RESULTS We found 15 randomized controlled trials matching our inclusion and exclusion criteria comprising 2796 total subjects. Short-course regimens primarily studied the use of azithromycin (n=10), but trials examining beta-lactams (n=2), fluoroquinolones (n=2), and ketolides (n=1) were found as well. Of the extended-course regimens, 3 studies utilized the same antibiotic, whereas 9 involved an antibiotic of the same class. Overall, there was no difference in the risk of clinical failure between the short-course and extended-course regimens (0.89, 95% confidence interval [CI], 0.78-1.02). In addition, there were no differences in the risk of mortality (0.81, 95% CI, 0.46-1.43) or bacteriologic eradication (1.11, 95% CI, 0.76-1.62). In subgroup analyses, there was a trend toward favorable clinical efficacy for the short-course regimens in all antibiotic classes (range of relative risk, 0.88-0.94). CONCLUSIONS The available studies suggest that adults with mild to moderate community-acquired pneumonia can be safely and effectively treated with an antibiotic regimen of 7 days or less. Reduction in patient exposure to antibiotics may limit the increasing rates of antimicrobial drug resistance, decrease cost, and improve patient adherence and tolerability.
Collapse
Affiliation(s)
- Jonathan Z Li
- Department of Medicine, San Francisco VA Medical Center, University of California, San Francisco, CA 94143-0862, USA.
| | | | | | | |
Collapse
|
36
|
Winston LG, Roemer M, Goodman C, Haller B. False-positive culture results from patient tissue specimens due to contamination of RPMI medium with Cryptococcus albidus. J Clin Microbiol 2007; 45:1604-6. [PMID: 17314221 PMCID: PMC1865871 DOI: 10.1128/jcm.02447-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cryptococcus albidus, a rare opportunist, was isolated from biopsy specimens from three patients over 4 days. An investigation showed that the specimens had been contaminated by placement in RPMI medium. The importance of rapid communication between the microbiology laboratory, the infectious diseases/infection control division, and other involved parties in the event of unusual occurrences is highlighted.
Collapse
Affiliation(s)
- Lisa G Winston
- University of California, San Francisco General Hospital, 1001 Potrero Avenue, Room 5H22, San Francisco, CA 94110, USA.
| | | | | | | |
Collapse
|
37
|
Young LS, Winston LG. Preoperative use of mupirocin for the prevention of healthcare-associated Staphylococcus aureus infections: a cost-effectiveness analysis. Infect Control Hosp Epidemiol 2006; 27:1304-12. [PMID: 17152027 DOI: 10.1086/509837] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Accepted: 09/22/2005] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Staphylococcus aureus is the most common cause of healthcare-associated infections. Intranasal mupirocin treatment probably decreases S. aureus infections among colonized surgical patients. Using cost-effectiveness analysis, we evaluated the cost-effectiveness of preoperative use of mupirocin for the prevention of healthcare-associated S. aureus infections. METHODS Three strategies were compared: (1) screen with nasal culture and give treatment to carriers, (2) give treatment to all patients without screening, and (3) neither screen nor treat. A societal perspective was taken. Adverse outcomes included bloodstream infection, pneumonia, surgical site infection, death due to underlying illness or infection, readmission, and the need for home health care. Data inputs were obtained from an extensive MEDLINE review and from publicly available government data sources. The following base-case data inputs (and ranges) for sensitivity analysis were used: rate of S. aureus carriage, 23.1% (19%-55%); efficacy of mupirocin treatment, 51% (8%-75%); mupirocin treatment cost, 48.36 US Dollars (24.18-57.74 US Dollars); and hospital costs of bloodstream infection, 25,128 US Dollars (6,194-40,211 US Dollars), pneumonia, 18,366 US Dollars (5,574-28,952 US Dollars), and surgical site infection 16,256 US Dollars (5,119-22,553 US Dollars). Widespread use of mupirocin has been associated with high levels of mupirocin resistance; therefore, a broad range of estimates for efficacy was tested in the sensitivity analysis. PATIENTS The target population included patients undergoing nonemergent surgery requiring postoperative hospitalization. RESULTS Both the screen-and-treat and treat-all strategies were cost saving, saving 102 US Dollars per patient screened and 88 US Dollars per patient treated, respectively. In 1-way sensitivity analyses, the model was robust with respect to all data inputs except for the efficacy of mupirocin treatment. If the efficacy is less than 16.1%, then the screen-and-treat strategy is cost incurring. A treat-all strategy was more cost saving if the rate of S. aureus carriage was greater than 42.7%, the mupirocin cost was less than 29.87 US Dollars, or nursing compensation was greater than 64.21 US Dollars per hour. CONCLUSION Administration of mupirocin before surgery is cost saving, primarily because healthcare-associated infections are very expensive. The level of mupirocin efficacy is critical to the cost-effectiveness of this intervention.
Collapse
Affiliation(s)
- Lisa S Young
- Department of Medicine, University of California, San Francisco, CA, USA.
| | | |
Collapse
|
38
|
Winston LG, Charlebois ED, Pang S, Bangsberg DR, Perdreau-Remington F, Chambers HF. Impact of a formulary switch from ticarcillin-clavulanate to piperacillin-tazobactam on colonization with vancomycin-resistant enterococci. Am J Infect Control 2004; 32:462-9. [PMID: 15573053 DOI: 10.1016/j.ajic.2004.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prevalence of vancomycin-resistant enterococci (VRE) is increasing, despite infection control measures. Limited data link ticarcillin-clavulanate to higher VRE prevalence. METHODS Active surveillance for VRE was conducted before and after a formulary switch from ticarcillin-clavulanate to piperacillin-tazobactam. Rectal swabs were obtained serially in 863 adult patients admitted to intensive care units (ICUs) between November 1, 2000 and September 30, 2004. RESULTS In the postswitch period, 38 of 497 (7.6%) patients acquired VRE versus 42 of 366 (11.5%) patients in the preswitch period. Survival analysis showed an overall hazard ratio (HR) of .68 postswitch versus preswitch ( P = .07), with the greatest change in the surgical ICU (HR = .17, P = .006). Multivariate analysis showed an overall HR = .51 ( P = .004). Hospital-wide, nonstool VRE clinical cultures fell from 39 (.58/1000 patient days) in the 10-month preswitch period to 27 (.33/1000 patient days) in the 12-month postswitch period. Infection control practices and use of other antibiotics remained stable. CONCLUSIONS VRE acquisition appeared to decrease in association with a formulary change from ticarcillin-clavulanate to piperacillin-tazobactam.
Collapse
Affiliation(s)
- Lisa G Winston
- Department of Medicine, Division of Infectious Diseases, University of California-San Francisco and SF General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA.
| | | | | | | | | | | |
Collapse
|
39
|
Young LS, Perdreau-Remington F, Winston LG. Clinical, Epidemiologic, and Molecular Evaluation of a Clonal Outbreak of Methicillin‐ResistantStaphylococcus aureusInfection. Clin Infect Dis 2004; 38:1075-83. [PMID: 15095210 DOI: 10.1086/382361] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2003] [Accepted: 12/01/2003] [Indexed: 11/03/2022] Open
Abstract
San Francisco General Hospital (San Francisco, CA) experienced an overall increase in the recovery of methicillin-resistant Staphylococcus aureus (MRSA) isolates that were shown by pulsed-field gel electrophoresis to have a genotype (genotype A1) that was new to this institution. We performed a case-control study to identify risk factors for acquiring genotype A1 MRSA infection from 1 October 2001 to 19 July 2002. Patients with genotype A1 MRSA infection were compared with 2 control groups: MRSA-infected control patients (i.e., patients with infection due to non-genotype A1 MRSA) and non-MRSA infected control patients (i.e., hospitalized patients without MRSA infection). There were 41 case patients infected with genotype A1 MRSA, 99 control patients infected with MRSA, and 41 control patients without MRSA infection. Pneumonia, surgical wound infections, and line infections occurred more frequently among case patients. Intensive care unit exposure and invasive procedures conferred the greatest risk for genotype A1 MRSA infection in multivariate models. Case patients were not associated with increased mortality, after adjusting for age, comorbidities, and intensive care unit exposure. Genotype A1 MRSA caused a large nosocomial outbreak of infection that was associated with distinct risk factors and clinical manifestations.
Collapse
Affiliation(s)
- Lisa S Young
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, California, USA
| | | | | |
Collapse
|
40
|
Winston LG, Pang S, Haller BL, Wong M, Chambers HF, Perdreau-Remington F. API 20 strep identification system may incorrectly speciate enterococci with low level resistance to vancomycin. Diagn Microbiol Infect Dis 2004; 48:287-8. [PMID: 15062923 DOI: 10.1016/j.diagmicrobio.2003.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2003] [Revised: 08/26/2003] [Accepted: 10/01/2003] [Indexed: 11/18/2022]
Abstract
The API 20 Strep system was used to speciate 46 enterococcal isolates with vancomycin MICs between 16-32 microg/mL. All were identified as Enterococcus faecium. Further testing revealed that 42/46 isolates had been identified incorrectly. Enterococci with low-level vancomycin resistance should not be speciated solely with the API 20 Strep system.
Collapse
Affiliation(s)
- Lisa G Winston
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco/San Francisco General Hospital, San Francisco, CA 94110, USA.
| | | | | | | | | | | |
Collapse
|
41
|
|
42
|
Winston LG, Bangsberg DR, Chambers HF, Felt SC, Rosen JI, Charlebois ED, Wong M, Steele L, Gerberding JL, Perdreau-Remington F. Epidemiology of vancomycin-resistant Enterococcus faecium under a selective isolation policy at an urban county hospital. Am J Infect Control 2002; 30:400-6. [PMID: 12410216 DOI: 10.1067/mic.2002.122647] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND We report our experience in a county hospital with the use of selective contact isolation for patients with vancomycin-resistant Enterococcus faecium (VREF). About 12% of patients with VREF are isolated for reasons such as draining wounds and uncontrolled diarrhea. METHODS Passive surveillance identified all inpatients (181) from 1995 to 1999 with cultures positive for VREF. Data were collected via electronic databases and from prospectively maintained infection control records. Isolates were typed with use of pulsed-field gel electrophoresis. RESULTS Nearly all patients (175/181) with VREF had been admitted at least 48 hours or had a history of previous hospitalization. Most patients (69%) had urine cultures positive for VREF without blood cultures positive for the organism. Only 12 of 127 (9.%) patients with complete data had VREF infection on the basis of receiving treatment and/or having more than 1 blood culture positive for VREF. After VREF became endemic, statistically significant increased prevalence was not detected via surveillance of clinical cultures nor sequential point-prevalence studies. Two major genotypes carrying vanB resistance genes were identified and persisted throughout the period studied. VREF persisted in individual patients up to 46 months. CONCLUSIONS The number of VREF infections in this facility has been low, despite appreciable colonization, for an extended period during which selective isolation was used.
Collapse
Affiliation(s)
- Lisa G Winston
- University of California, San Francisco/San Francisco General Hospital, 94110, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Winston LG, Perlman JL, Rose DA, Gerberding JL. Penicillin-nonsusceptible Streptococcus pneumoniae at San Francisco General Hospital. Clin Infect Dis 1999; 29:580-5. [PMID: 10530451 DOI: 10.1086/598637] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Positive pneumococcal cultures of specimens from adult inpatients at San Francisco General Hospital (SFGH) during the period of 11 August 1994 through 31 December 1996 were identified retrospectively. Of the isolates recovered, 15.5% were not penicillin-susceptible (MIC, > or =.1 microg/mL). A case-control study was performed to evaluate risk factors for colonization or infection with penicillin-nonsusceptible Streptococcus pneumoniae (PNSP) and outcomes. Cases (n = 65) were adult inpatients with a positive culture for PNSP, and controls (n = 411) were adult inpatients with a positive culture for penicillin-susceptible pneumococci (PSSP) and no evidence of PNSP. Cases were less likely to have pneumococcal bacteremia (15.4% versus 39.4%; P<.001) and less likely to have pneumonia (50.8% versus 68.9%; P = .006). In a multiple logistic regression model, recent hospital admission and absence of bacteremia were independent predictors of penicillin-nonsusceptibility. Human immunodeficiency virus infection, mortality, and length of hospitalization were not significantly different among cases and controls. These data suggest that PNSP may be less virulent (cause less pulmonary infection) and/or less invasive (cause fewer bloodstream infections) than PSSP at SFGH.
Collapse
Affiliation(s)
- L G Winston
- Center for Epidemiology & Prevention Interventions, Department of Medicine, University of California, San Francisco 94143-0654, USA
| | | | | | | |
Collapse
|