The Epidemiology of Community-Acquired Clostridium difficile Infection: A Population-Based Study

Abstract

Background Clostridium difficile infection (CDI) is a common hospital-acquired infection with increasing incidence, severity, recurrence and associated morbidity and mortality. There is emerging data on the occurrence of CDI in non-hospitalized patients. However, there is a relative lack of community-based CDI studies, as most of the existing studies are hospital-based, potentially influencing the results by referral or hospitalization bias by missing cases of community-acquired CDI. Methods To better understand the epidemiology of community-acquired Clostridium difficile infection, a population-based study was conducted in Olmsted County, Minnesota using the resources of the Rochester Epidemiology Project. Data regarding severity, treatment response, and outcomes were compared in community-acquired versus hospital-acquired cohorts, and changes in these parameters, as well as in incidence, were assessed over the study period. Results Community-acquired Clostridium difficile infection cases accounted for 41% of 385 definite CDI cases. The incidence of both community-acquired and hospital-acquired Clostridium difficile infection increased significantly over the study period. Compared to those with hospital-acquired infection, patients with community-acquired infection were younger (median age 50 years compared to 72 years), more likely to be female (76% versus 60%), had lower comorbidity scores, and were less likely to have severe infection (20% versus 31%) or have been exposed to antibiotics (78% versus 94%). There were no differences in the rates of complicated or recurrent infection in patients with community-acquired compared to hospital-acquired infection. Conclusions In this population-based cohort, a significant proportion of cases of Clostridium difficile infection occurred in the community. These patients were younger and had less severe infection than those with hospital-acquired infection. Thus, reports of Clostridium difficile infection in hospitalized patients likely underestimate the burden of disease and overestimate severity.

Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series

“…2,3 Since the emergence of the hypervirulent NAP1/027 strain in recent years, there has been an increase in the severity of CDI, with more patients failing medical therapy and requiring emergent colectomy. 2,4,5 Recent epidemiologic data suggests that CDI is a growing burden among surgical patients and is associated with increased morbidity, mortality, hospital stay and health care costs.…”

The host immune response to Clostridium difficile infection

“…An increasing number of cases of CDI (20 41%) involve patients who do not conform to the traditional risk factors [Khanna and Pardi, 2010;Lessa et al 2012]. The majority of these cases are community acquired and involve significantly younger patients with lower comorbidity scores and lower rates of antibiotic exposure [Khanna et al 2011]. Vaccination strategies currently under consideration to prevent primary and recurrent CDI would target adults most at risk, that is, those with planned hospitalization, long-term care/nursing home residents and adults with comorbidities requiring frequent/prolonged antibiotic use [Foglia et al 2012].…”

Clostridium difficile infection: management strategies for a difficult disease

“…Studies in the pediatric population have shown that the incidence in children has increased up to 12.5-fold in the last two decades [Khanna et al 2013b;Kim et al 2008]. Adult patients with communityacquired CDI are younger, have fewer comorbidities and less frequently have severe disease than patients with hospital-acquired infection [Khanna et al 2012g]. Hence, CDI is now commonly being identified in populations that were previously considered to be low-risk such as children and community dwellers who lack traditional risk factors for CDI [Khanna et al 2012f;Chitnis et al 2013;Lessa, 2013].…”

“…A population-based study from Olmsted County, MN, showed that the incidence of both communityacquired increased by 5.3 fold from 1991 to 2005, and a large proportion of cases (41%) were community-acquired [Khanna et al 2012g]. Studies in the pediatric population have shown that the incidence in children has increased up to 12.5-fold in the last two decades [Khanna et al 2013b;Kim et al 2008].…”

“…The risk of recurrent CDI after initial treatment of the first infection is approximately 20-25% [Kelly and Lamont, 2008;Khanna et al 2012g] and is further increased up to 60% with the use of additional systemic antibiotics and subsequent CDI recurrences [Hu et al 2009]. The pathophysiology of recurrent CDI involves ongoing disruption of the normal fecal flora and an inadequate host immune response.…”