Hospital-onset Clostridioides difficile infections during the COVID-19 pandemic

Abstract

To the Editor-Clostridioides difficile infection (CDI) is the most common healthcare-associated infection in the United States. 1 CDI affects 13 in every 1,000 patients, and~75% of cases are classified as hospital onset. Antimicrobial stewardship and compliance with hand hygiene and personal protective equipment (PPE) protocols are paramount in efforts to reduce horizontal CDI transmission. 2 As an epicenter of the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), New York City hospitals saw a dramatic increase in admissions and ICU utilization. 3 To understand the impact of COVID-19 on hospital-onset CDI, we examined antibiotic prescribing patterns, standardized infection ratios (SIRs), and baseline variables in hospitalized adult patients prior to and during the COVID-19 pandemic. We hypothesized that increased antibiotics exposure during the COVID-19 pandemic would lead to a higher incidence of CDI in hospitalized patients. We conducted a retrospective cohort analysis at a high-volume tertiary-care center comparing a pre-COVID-19 cohort (February-June 2019) of all adult patients who were diagnosed with CDI on admission or during their hospitalization with a cohort during the COVID-19 pandemic (February-June 2020). Baseline categorical variables were compared using χ 2 tests and continuous variables were compared using the Student t test and Mann-Whitney-Wilcoxon test. All analysis was performed in SAS version 9.4 software (SAS Institute, Cary, NC). Primary outcomes of interest included rates of hospital-onset CDI (HO-CDI, defined as a positive C. difficile test over 3 days after admission), 4 antibiotic prescribing and length of stay. HO-CDI incidence was described by the standardized infection ratios (SIR), which adjusts for facility and patient-level factors that contribute to hospitalonset infection risk within each facility. Antibiotic prescriptions were measured by antibiotic days per 1,000 days present. The study was approved by the Institutional Review Board of the Icahn School of Medicine at Mount Sinai. Overall, HO-CDI SIR 5 was not statistically different during the COVID-19 period than during the 2019 period (P = 0.69)

<i>Clostridioides difficile</i> infection in coronavirus disease 2019: an underestimated problem?

“…Even though the probability of this has always been regarded as high and has been speculated upon [34], the high rate of CDI and COVID-19 coinfection still remains unproven. We acknowledge that the findings of our study are in contrast to other recent publications, one of which reported a lower incidence of CDI [21], while another a similar incidence of CDI [20] among patients with SARS-CoV-2 infection. The universal use of personal protective equipment (PPE), including gowns and gloves, can account for a diminished rate of CDI coinfection.…”

“…The studied cohort from Detroit Medical Center from March 11 th -April 22 nd 2020 was composed of elderly females with SARS-CoV-2 infection. Two other reports [20,21] have presented contradictory findings: a decreased number of cases and a stable number of cases compared to the pre-pandemic era. It is possible that the problem of CDI in COVID-19 patients is underestimated.…”

“…Therefore, although we are convinced that our data hold true, we are unable to explain why the results obtained at different centers vary so much. In a retrospective cohort from New York reported by Luo et al [20], there was a trend towards a higher percentage of positive tests but a lower percentage of tests sent as compared to the pre-pandemic era. Similarly, in a report from Madrid [21], there was a 9.8% reduction in the rate of requests for CD tests.…”

The Interplay of SARS-CoV-2 and Clostridioides Difficile Infection

“…An interesting retrospective cohort analysis from New York, NY compared a pre-COVID-19 cohort of all adult patients diagnosed with CDI with a cohort during the COVID-19 pandemic [ 9 ]. Overall, hospital onset standardized infection ratios were not different in hospital-onset CDI rate despite a trend toward increased high-risk antibiotic exposure.…”

“…Overall, hospital onset standardized infection ratios were not different in hospital-onset CDI rate despite a trend toward increased high-risk antibiotic exposure. There was a trend toward an increased length of stay and a trend toward decreased C. difficile testing volumes, suggesting that patients’ diarrhea and gastrointestinal symptoms could have been attributed to COVID-19 [ 9 ]. A possible explanation could be increased and enhanced infection control measures seen in healthcare facilities during the COVID-19 pandemic.…”