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Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in Biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control and has worked in both pediatric and adult acute care facilities.

A Timestamp for C diff

JUL 11, 2019 | SASKIA V. POPESCU
Every year in the United States, half a million people suffer from Clostridioides difficile (C diff) infections. This painful inflammation of the colon leads to diarrhea that can be devastating to the patient and challenging for infection control efforts. The US Centers for Disease Control and Prevention (CDC) estimates that there are 15,000 deaths directly attributable to C diff each year in the United States. Unfortunately, there are a lot of compounding factors that make prevention and control challenging. 
 
The environmental hardiness of the C diff spore means that cleaning and disinfection practices require an extra effort—the use of bleach-based products. This can make transmission within health care facilities easier, meaning rapid identification, isolation, treatment, and proper disinfection are absolutely critical. The timing of these infections, though, can be problematic, as current recommendations state that C diff cases identified (ie, laboratory confirmed) on or after day 4 of hospitalization, are considered a health care-associated case.
    
A new study by St. Joseph’s Healthcare in Hamilton, Canada, and published in the American Journal of Infection Control sought to really analyze the timelines of C diff infections and how they play into diagnosis, isolation, and even treatment. The investigators noted that the research arose from a need for descriptive analyses of C diff infections based on administrative databases. “These timelines relate directly to the costs and strategies for treatment and prevention of health care-associated CDI; for example, the onset of CDI symptoms marks the start of an observable window of opportunity for infection transmission, either through the shedding of spores into the environment or by direct contact with individuals,” investigators wrote. To fill this gap, the team worked to estimate C diff infection timelines based on the analysis of Canadian hospital data over 5 years. 

Investigators analyzed data from January 1, 2013, through December 30, 2017, within this regional health center. Data points included symptom onset, test results, relapses, treatment, etc. This information not only provided insight into when a case was being identified as community-onset, but also general timeframes for hospital-onset cases.

Of the 683 cases of C diff identified during this time period, nearly 55% of cases were documented in females, with a mean patient age of 70.9 years. The incidence of C diff ranged from 3 to 7.5 cases per 10,000 patient days, and a range of 120-170 cases per year. Excluding 84 cases due to gaps in data, the investigators found 202 cases with symptom onset prior to hospitalization and 397 cases with symptom onset following hospital admission. The research team found that the time interval from admission to C diff symptom onset for health care-associated infections (HAI) cases was 21.6 days and 2.1 days for those considered to be community-associated infections (CAI).

“The mean time intervals between the onset of CDI symptoms after admission and the release of laboratory results were 1.2 days and 1.9 days for the HAI and community-associated infection (CAI) patient groups, respectively. The mean time intervals from symptoms onset to the start of isolation were 1.5 days and 2.6 days for the corresponding patient groups,” investigators wrote.    

There were substantial differences in the mean time intervals between HAI and CAI cases for those with symptom onset prior to admission, in the time between symptom onset to lab results, symptom onset to start of isolation, and symptom onset to start of treatment. The investigators found the duration of isolation had a mean of 20.5 days and a median of 14 days. Moreover, they found that 84.3% of patients experienced no relapse. 

Overall, this study sheds light on the timelines associated with C diff that we often fail to recognize or incorporate in response efforts. For those patients admitted with symptoms, they usually experience 5-10 days of symptoms prior to their hospitalization, which means there is considerable risk to the community. The delay in treatment for C diff cases in which symptom onset was post-admission, was actually shorter than previous studies have shown.

The investigators also found that the initiation of treatment within 2 days of symptoms helped reduced the duration of isolation, which was statistically significant. For those with symptom onset following admission, there wasn’t a statistically significant relationship between estimated timelines. What we can take away, though, is that not only should analysis of such timelines be more prevalent in health care facilities, but we can better work to educate and enhance patient safety through these trends. 
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