Epidemiology and Outcomes of Community-Acquired Clostridium difficile Infections in Medicare Beneficiaries

Abstract

Background The incidence of community-acquired Clostridium difficile (CACD) is increasing in the US. Many CACD infections occur in the elderly who are predisposed to poor outcomes. We aimed to describe the epidemiology and outcomes of CACD in a nationally representative sample of Medicare beneficiaries. Study Design We queried a 5% random sample of Medicare beneficiaries (2009–2011 Part A inpatient and Part D prescription drug claims, N=864,604) for any hospital admission with a primary ICD-9 diagnosis code for C. difficile (008.45). We examined patient sociodemographic and clinical characteristics, pre-admission exposure to oral antibiotics, prior treatment with oral vancomycin or metronidazole, inpatient outcomes (colectomy, ICU stay, length of stay, mortality), and subsequent admissions for C. difficile. Results A total of 1566 (0.18%) patients were admitted with CACD. Of these, 889(56.8%) received oral antibiotics within 90 days of admission. Few were being treated with oral metronidazole (N=123, 7.8%) or vancomycin (N=13, 0.8%) at the time of admission. While 223(14%) patients required ICU admission, few (N=15, 1%) underwent colectomy. Hospital mortality was 9%. Median length of stay (LOS) among survivors was 5 days (IQR 3–8). One- fifth of survivors were re-admitted with C. difficile with a median follow up time of 393 days (IQR 129–769). Conclusions Nearly half of Medicare beneficiaries admitted with CACD have no recent antibiotic exposure. High mortality and re-admission rates suggest that the burden of C. difficile on patients and the healthcare system will increase as the US population ages. Additional efforts at primary prevention and eradication may be warranted.

Recurrent Clostridium difficile infection: From colonization to cure

“…This trend promotes the notion that C. difficile spore and/or bacillus exposure may be sufficient for the development of active infection regardless of the presence of other major predisposing factors such as older age or underlying comorbidity 49 . Even so, it is important to recognize that the majority of CA-CDI patients do not develop the infection de novo, as antibiotic use is still a factor in 50–80% of such cases 50, 51 . It is unclear, however, whether community-acquisition of C. difficile has any effect on a patient’s chance of recurrence.…”

Challenges in the Diagnosis and Management of Inflammatory Bowel Disease in the Elderly

“…Stool studies for infectious organisms are essential in ruling out colitis secondary to microbial pathogens, particularly Clostridium difficile, which is associated with a 20 % rehospitalization rate and 9 % mortality in hospitalized elderly patients [16]. In 2012, approximately 98 million NSAID prescriptions were written and 29 million people were on chronic NSAIDs [17].…”

Proton Pump Inhibitors Do Not Increase Risk for Clostridium difficile Infection in the Intensive Care Unit

“…Risk factors associated with the development of CDI have been studied extensively in the community (9–14) and among inpatients (15–21), but the risk factors for the onset of CDI among ICU patients have received less attention (22–26). Among hospitalized patients, established risk factors for incident CDI include older age and comorbid medical conditions such as impaired renal function and low serum albumin (27, 28).…”