Incidence of Hospital-Acquired C Diff Declines, But Challenges Remain: Public Health Watch

When you’re in the middle of a global pandemic, it’s easy to forget about a fairly mundane public health challenge such as Clostridioides difficile Infection (CDI).

However, as all loyal Contagion® readers know, CDI is anything but boring. The infection sickens more than 400,000 people in the United States each year, causing death in more than 25,000—roughly the same number, as of this writing, taken from us far too soon by coronavirus disease 2019.

So, this is serious business—obviously—which is why the findings of a new analysis published on April 2^nd by The New England Journal of Medicine serve as a spot of good news in a year full of demoralizing findings, from a public health perspective, at least to date. The authors noted that the number of CDI cases across the country appeared to drop by 24% between 2011 and 2017, the most recent year for which data are available.

“This was driven by a 36% decrease in cases of healthcare-associated CDI, while community-associated CDI was unchanged,” Danyel M. Olson MS, MPH, CDI Surveillance Coordinator, Connecticut Emerging Infections Program/Yale School of Public Health, told Contagion®. “We think this decrease is because CDI prevention has been a national priority. There are efforts to improve infection prevention and antibiotic and diagnostic stewardship expanding across all healthcare settings, particularly in hospital settings.”

Community-associated cases now account for roughly 50% of CDI prevalence in the United States, the authors noted.

In an era in which science is often ignored and evidence-based public-health practice dismissed, Olson optimistically suggests that these findings “increased awareness of the challenges associated with C difficile.” Indeed, in recent years, as he notes, hospitals have been encouraged and/or required to have antibiotic stewardship programs—and these programs have helped reduce the numbers of hospital-acquired cases of CDI and other significant infections.

However, these same protocols have not been applied to clinics and other outpatient health care settings—hence, the increase in community-acquired CDI.

To address this gap, Olson and his colleagues—who include investigators from the US Centers for Disease Control and Prevention as well as from various local public health departments across the country—recommend the following:

• That health care institutions continue to work to improve adherence to recommended infection-prevention measures and implement diagnostic and antibiotic stewardship in both inpatient and outpatient settings;
• That policymakers promote guidelines for infection control, build prevention collaboratives in states with high CDI rates, address critical questions such as the role of asymptomatic carriers, transmission dynamics, the patient’s microbiome, and health care cleaning and disinfection; and,
• That leaders in the field encourage implementation of antibiotic stewardship programs in all healthcare settings, including dental offices and outpatient settings, focusing on specific antibiotics linked to C difficile, and assessing national progress in reducing CDI by using Emerging Infections Program (EIP) data to estimate burden and tracking hospital-onset C difficile through the National Healthcare Safety Network (NHSN).

“There tends to be less infrastructure in outpatient settings, when compared to hospitals, for both infection prevention and antibiotic stewardship,” Olson said. “More efforts are needed in outpatient settings to understand the extent of over-testing which might be occurring, use of unnecessary antibiotics, and a better understanding of other ways C difficile might be spread in the community. This will help target prevention strategies.”