Zakażenie clostridioides difficile

Zakażenie clostridioides difficile
Epidemiologia

Zakażenie Clostridioides difficile (CDI) stanowi istotne wyzwanie zdrowia publicznego, z roczną częstością występowania w USA na poziomie 116,1/100 000 osób i 3,48/10 000 pacjento-dni w Europie. CDI jest główną przyczyną biegunek poantybiotykowych oraz zakażeń związanych z opieką zdrowotną, powodując około 500 000 zakażeń i 29 000 zgonów miesięcznie w USA. Epidemiologia uległa zmianie – spada częstość zakażeń szpitalnych (HA-CDI: 57,9/100 000), natomiast wzrasta liczba zakażeń nabytych w społeczności (CA-CDI: 63,3/100 000). Dominujące szczepy uległy zmianie, z malejącą rolą rybotypu 027 i wzrostem rybotypów 106, 002 i 014/020. Główne czynniki ryzyka to ekspozycja na środowisko opieki zdrowotnej, wiek ≥65 lat oraz stosowanie antybiotyków, zwłaszcza karbapenemów, klindamycyny, fluorochinolonów, piperacyliny z tazobaktamem i cefalosporyn III/IV generacji. Nawroty występują u około 25% pacjentów po pierwszym epizodzie, z ryzykiem wzrastającym do ponad 60% po trzech epizodach, co generuje dodatkowe obciążenie kliniczne i ekonomiczne.

Epidemiologia zakażenia Clostridioides difficile

Zakażenie Clostridioides difficile (ang. Clostridioides difficile infection, CDI) stanowi poważne wyzwanie dla zdrowia publicznego na całym świecie. W ostatnich dekadach obserwuje się znaczące zmiany w epidemiologii tego zakażenia, zarówno pod względem częstości występowania, jak i ciężkości przebiegu. Bakteria Clostridioides difficile jest główną przyczyną biegunki związanej z antybiotykoterapią oraz jednym z najczęstszych patogenów powodujących zakażenia związane z opieką zdrowotną.¹²

Skala problemu na świecie

Według danych Centrum Kontroli i Zapobiegania Chorobom (CDC) w Stanach Zjednoczonych C. difficile powoduje około 500 000 zakażeń rocznie, prowadząc do około 29 000 zgonów w ciągu miesiąca od rozpoznania.¹² Bezpośrednio z zakażeniem C. difficile wiąże się około 15 000 z tych zgonów. Ponadto około 83 000 pacjentów doświadcza przynajmniej jednego nawrotu zakażenia, a 29 000 z nich umiera w ciągu 30 dni od początkowego rozpoznania.³

W 2022 roku w Stanach Zjednoczonych wskaźnik zachorowalności na CDI wynosił 116,1 przypadków na 100 000 osób.¹ Natomiast w Europie, według badania przeprowadzonego w 2022 roku obejmującego 559 szpitali, średnia częstość występowania CDI wynosiła 3,48 przypadku na 10 000 pacjento-dni.¹ Dane te różnią się znacząco w zależności od kraju i regionu.

Należy podkreślić, że zakażenia C. difficile stanowią znaczne obciążenie ekonomiczne dla systemów opieki zdrowotnej. W Stanach Zjednoczonych bezpośrednie koszty leczenia CDI w szpitalach szacowane były na 4,8 miliarda dolarów w 2008 roku, jednak rzeczywiste koszty są prawdopodobnie wyższe, gdy uwzględni się koszty pośrednie związane z zarządzaniem CDI.¹

Trendy epidemiologiczne

Epidemiologia zakażeń C. difficile uległa znaczącym zmianom od początku XXI wieku. Obserwuje się wyraźny wzrost zachorowalności i ciężkości przebiegu zakażeń, szczególnie u osób starszych.¹ Początkowo CDI było głównie problemem związanym z opieką szpitalną, jednak obecnie zakażenia pojawiają się również w środowisku pozaszpitalnym, u osób wcześniej uważanych za grupę niskiego ryzyka.²

Dane z Ameryki Północnej i Europy sugerują, że około 20-27% wszystkich przypadków CDI jest związanych ze środowiskiem pozaszpitalnym, z częstością występowania 20-30 na 100 000 populacji.¹ Według CDC, w ostatnich latach obserwuje się spadek częstości występowania zakażeń związanych z opieką zdrowotną (HA-CDI), podczas gdy zakażenia nabyte w społeczności (CA-CDI) wykazują tendencję wzrostową, niemal podwajając się w ciągu ostatniej dekady.¹

CDC raportuje, że wskaźnik zachorowalności na HA-CDI (definiowane jako zakażenia z początkiem w placówce opieki zdrowotnej lub związane z niedawnym przyjęciem do placówki opieki zdrowotnej) wynosi 57,9 przypadków na 100 000 osób, co stanowi znaczny spadek w ostatnich latach. Z kolei CA-CDI wykazuje tendencję wzrostową, osiągając częstość 63,3 przypadków na 100 000 osób.²

Interesującym zjawiskiem jest zmiana dominujących szczepów C. difficile. W latach 2003-2006 zaobserwowano pojawienie się wysoce wirulentnego szczepu rybotypu 027 (BI/NAP1/027), który został powiązany z dużymi ogniskami epidemicznymi oraz zwiększoną częstością występowania i ciężkością przebiegu CDI.¹ Obecnie, przypadki wywołane przez rybotyp 027 znacznie spadły w USA, Kanadzie i Europie. W USA w 2017 roku częstość występowania szczepu 027/BI/NAP1 wynosiła 15% w przypadku HA-CDI i 6% w przypadku CA-CDI. Obecnie nie jest to już dominujący szczep w USA, gdzie wzrosła częstość występowania rybotypów 106, 002 i 014/020.¹

Czynniki ryzyka i grupy wysokiego ryzyka

Zidentyfikowano szereg czynników zwiększających ryzyko zakażenia C. difficile. Główne czynniki ryzyka obejmują:¹

Ekspozycję na środowisko opieki zdrowotnej
Podeszły wiek (65 lat lub więcej)
Ekspozycję na antybiotyki

Stosowanie antybiotyków jest najważniejszym modyfikowalnym czynnikiem ryzyka zarówno dla pierwotnego, jak i nawrotowego CDI. Chociaż większość antybiotyków może zaburzać prawidłową florę jelitową, tym samym tworząc środowisko sprzyjające rozwojowi i kolonizacji C. difficile, najwyższe ryzyko zakażenia stwarzają karbapenemy, klindamycyna, fluorochinolony, piperacylina z tazobaktamem oraz cefalosporyny trzeciej i czwartej generacji.²

Pacjenci są najbardziej narażeni na CDI podczas antybiotykoterapii i w ciągu pierwszego miesiąca po jej zakończeniu, a ryzyko utrzymuje się przez 3 miesiące po zakończeniu leczenia.³ Inne czynniki ryzyka CDI obejmują:¹²

Immunosupresję
Hospitalizację lub pobyt w placówce opieki długoterminowej
Choroby zapalne jelit
Stosowanie leków zmniejszających wydzielanie kwasu żołądkowego (inhibitory pompy protonowej, antagoniści H2)
Zabiegi chirurgiczne przewodu pokarmowego
Wcześniejsze epizody CDI

Badania wskazują, że stosowanie leków zmniejszających wydzielanie kwasu żołądkowego (inhibitorów pompy protonowej i antagonistów receptora H2) może być jednym z najczęściej występujących czynników ryzyka CDI, co potwierdzono w licznych badaniach.¹

Nawroty zakażenia C. difficile

Nawrotowe zakażenia C. difficile (rCDI) stanowią poważne wyzwanie kliniczne. Około 25% pacjentów z pierwszym epizodem CDI doświadczy nawrotu zakażenia.¹ Ryzyko nawrotu wzrasta wraz z liczbą epizodów CDI – do 45% pacjentów doświadcza nawrotu po drugim epizodzie i ponad 60% po trzech lub więcej epizodach.²

Dane wskazują, że w USA nawroty odpowiadają za dodatkowe 75 000 do 175 000 przypadków CDI rocznie.¹ Według najnowszych szacunków, wskaźnik nawrotów w USA wynosi około 31 300 i 38 500 przypadków odpowiednio dla CA-CDI i HA-CDI w 2017 roku.¹

W Europie wskaźniki nawrotów CDI wahają się od 3,7% do 64,0% dla HA-CDI oraz od 3,1% do 28,0% dla CA-CDI. We wszystkich przypadkach wskaźnik nawrotów jest niższy w zakażeniach nabytych w społeczności niż w zakażeniach związanych z opieką zdrowotną.¹

Systemy nadzoru nad zakażeniami C. difficile

W odpowiedzi na rosnące zagrożenie związane z zakażeniami C. difficile, wiele krajów wdrożyło systemy nadzoru epidemiologicznego w celu monitorowania częstości występowania i trendów w zakresie tych zakażeń.¹

Systemy nadzoru w Stanach Zjednoczonych

W Stanach Zjednoczonych CDC uruchomiło aktywny, populacyjny nadzór nad CDI w ramach programu Emerging Infections Program (EIP).¹ Program ten identyfikuje i monitoruje:²

Częstość występowania i obciążenie CDI w społecznościach i placówkach opieki zdrowotnej
Trendy w zakresie choroby w czasie, w tym zmiany w częstości występowania szczepów

Dane te są zbierane przez przeszkolonych specjalistów prowadzących aktywny nadzór populacyjny i laboratoryjny w 10 ośrodkach EIP.³ Pracownicy EIP identyfikują przypadki na podstawie raportów o pozytywnych wynikach badań na obecność toksyny C. difficile lub badań amplifikacji kwasu nukleinowego C. difficile z laboratoriów klinicznych, referencyjnych i komercyjnych obsługujących mieszkańców obszarów objętych nadzorem.¹

Część przypadków podlega kompleksowemu przeglądowi dokumentacji medycznej w celu uzyskania informacji klinicznych i istotnych czynników ryzyka. Pracownicy EIP zbierają również próbki kału od wybranych pacjentów z przypadkami CDI, dla których wypełniono formularze raportów przypadków.²

Systemy nadzoru w Europie

Od 1 stycznia 2016 r. Europejskie Centrum ds. Zapobiegania i Kontroli Chorób (ECDC) koordynuje nadzór nad zakażeniami C. difficile w szpitalach świadczących opiekę w stanach ostrych w krajach UE/EOG. Protokół nadzoru ECDC zapewnia standaryzowane narzędzie do pomiaru i monitorowania wskaźników zachorowań na CDI, z trzema opcjami nadzoru: minimalną, podstawową i rozszerzoną, przy czym ta ostatnia łączy oparte na przypadkach dane epidemiologiczne i mikrobiologiczne.¹

W latach 2016-2017 24 kraje/administracje UE/EOG zgłosiły dane dotyczące CDI do ECDC, z czego 23 kraje miały dane odpowiednie do analizy. Dane dotyczące CDI w 2017 r. pochodziły z 21% szpitali świadczących opiekę w stanach ostrych w uczestniczących krajach/administracjach i 10% wszystkich szpitali świadczących opiekę w stanach ostrych w UE/EOG.²

W latach 2016-2017 surowa gęstość częstości występowania CDI wynosiła 3,48 przypadku na 10 000 pacjento-dni. W tym okresie 23 052/37 857 (60,9%) przypadków stanowiły HA-CDI, a 2 439/37 857 (6,4%) przypadków CDI zostało zgłoszonych jako nawroty. Ponadto 12 366/37 857 (32,7%) przypadków CDI było związanych ze społecznością (CA CDI) lub miało nieznane powiązanie (UA CDI).¹

ECDC zaleca ciągły nadzór nad częstością występowania CDI przez okres 12 miesięcy. Jeżeli nie jest to możliwe, ECDC zaleca minimalny okres nadzoru wynoszący trzy miesiące.²

Standardyzacja nadzoru epidemiologicznego

Aby zwiększyć porównywalność danych między różnymi placówkami opieki zdrowotnej, opracowano standardowe definicje przypadków do nadzoru nad:¹

CDI z początkiem w placówce opieki zdrowotnej (HO-CDI)
CDI z początkiem w społeczności, ale związanym z placówką opieki zdrowotnej (CO-HCFA CDI)
CDI związanym ze społecznością (CA-CDI)

Zaleca się, aby wskaźnik HO-CDI był wyrażany jako liczba przypadków na 10 000 pacjento-dni, a wskaźnik częstości występowania CO-HCFA jako liczba przypadków na 1 000 przyjęć pacjentów.¹

Strategia nadzoru powinna obejmować stratyfikację danych według lokalizacji pacjentów, aby ukierunkować środki kontrolne, gdy częstość występowania CDI przekracza krajowe i/lub lokalne cele redukcji lub gdy zauważono ognisko epidemiczne.²

Znaczenie nowoczesnych technologii w nadzorze

Nowoczesne technologie, takie jak sekwencjonowanie całego genomu i analiza wielolokusowych powtórzeń tandemowych o zmiennej liczbie, pomagają śledzić przenoszenie C. difficile między placówkami opieki zdrowotnej, krajami i kontynentami, oferując możliwość odkrycia wcześniej niedocenianych źródeł zakażenia.¹

Jednak porównanie epidemiologii CDI, szczególnie między krajami, jest trudne ze względu na szeroki zakres podejść do pobierania próbek i testowania.¹ Zaleca się wieloetapowe algorytmy diagnostyczne w celu poprawy czułości i swoistości testów.²

Transmisja i drogi szerzenia się zakażenia

C. difficile jest wszechobecne i może kolonizować jelita do 3-5% zdrowych osób bez powodowania zakażeń. Chociaż transmisja C. difficile odbywa się głównie drogą fekalno-oralną, może ona również wynikać z różnych innych źródeł środowiskowych, takich jak gleba.¹

Transmisja w środowisku opieki zdrowotnej

Bakteria jest częściej przenoszona za pośrednictwem zanieczyszczonych powierzchni w szpitalach, często w postaci przetrwalników. Zanieczyszczone powierzchnie i sprzęt medyczny w placówkach opieki zdrowotnej mogą stać się rezerwuarami przetrwalników C. difficile, potencjalnie przenosząc się na pacjentów, jeśli nie są egzekwowane odpowiednie praktyki zapobiegania i kontroli zakażeń, w tym odpowiednie protokoły czyszczenia.²

Środowisko opieki zdrowotnej stwarza sprzyjające warunki do transmisji C. difficile ze względu na trudności w eliminacji przetrwalników oraz powszechne stosowanie środków przeciwdrobnoustrojowych, które sprzyja rozwojowi zakażeń C. difficile.³

Bezobjawowe nosicielstwo a transmisja

Bezobjawowi nosiciele C. difficile, definiowani jako osoby, które noszą organizm C. difficile bez objawów klinicznych wskazujących na zakażenie, mogą być niedocenianymi rezerwuarami C. difficile w placówkach opieki zdrowotnej. Bezobjawowi nosiciele są częstsi w szpitalu niż pacjenci z objawami: wykazano, że nawet 29% pacjentów w stanie ostrym w placówkach opieki ostrodyżurowej bezobjawowo przenosi C. difficile.¹

Ryzyko transmisji od niezidentyfikowanych, bezobjawowych nosicieli może być również wyższe niż od pacjentów z objawami, ponieważ nosiciele mogą wydalać przetrwalniki do środowiska, ale zwykle nie są objęci takimi samymi środkami ostrożności i ich pokoje mogą nie być poddawane takim samym procedurom czyszczenia jak u pacjentów z CDI.²

Potencjalne źródła ekspozycji w społeczności

Potencjalne źródła ekspozycji w społeczności można ogólnie podzielić na:¹

Spożycie (połknięcie przetrwalników z zanieczyszczonego produktu spożywczego)
Kontakt osoby z osobą (przeniesienie z innej zakażonej lub skolonizowanej osoby)
Kontakt zwierzęcia z osobą (przeniesienie z zakażonego lub skolonizowanego zwierzęcia domowego lub dzikiego)
Kontakt środowiska z osobą (połknięcie przetrwalników po ekspozycji na zanieczyszczone źródło środowiskowe)

Znaczenie znalezienia niskich bezwzględnych liczby C. difficile w próbkach środowiskowych jest niejasne, podczas gdy dawka zakaźna pozostaje nieznana; wykrycie w dowolnej liczbie źródeł może mieć lub nie mieć znaczenia dla zdrowia publicznego.²

Istnieje potencjał dla C. difficile do działania jako patogen przenoszony drogą pokarmową, co badało wielu autorów. Jednak obecnie nie ma wystarczających dowodów epidemiologicznych łączących spożycie zanieczyszczonej żywności ze wzrostem CA-CDI.¹

Wnioski i przyszłe wyzwania

Epidemiologia zakażeń C. difficile podlega ciągłym zmianom. Mimo że w ostatnich latach obserwuje się spadek częstości występowania HA-CDI w wielu krajach rozwiniętych, CA-CDI staje się coraz większym problemem. Nawroty zakażenia stanowią szczególne wyzwanie kliniczne i są związane ze znacznym obciążeniem dla systemów opieki zdrowotnej.¹

Skuteczne strategie kontroli i zapobiegania CDI powinny obejmować:¹

Środki zapobiegania zakażeniom (np. higiena rąk, środki izolacji, środki ostrożności dotyczące kontaktu oraz odpowiednie czyszczenie i dezynfekcja środowiska)
Wdrażanie programów zarządzania antybiotykami, które ograniczają stosowanie antybiotyków wysokiego ryzyka i koncentrują się na minimalizowaniu stosowania i czasu trwania niepotrzebnych środków przeciwdrobnoustrojowych

Wyzwaniem pozostaje standaryzacja metod nadzoru i diagnostyki CDI na poziomie międzynarodowym, co pozwoliłoby na bardziej wiarygodne porównania epidemiologiczne między różnymi regionami i krajami.¹

Zrozumienie dynamiki transmisji C. difficile, w tym roli bezobjawowych nosicieli, jest kluczowe dla opracowania skutecznych strategii zapobiegania. Badania wskazują, że obecne praktyki zapobiegania zakażeniom mogą być skuteczne w zapobieganiu szpitalnemu przenoszeniu C. difficile, a dalsze zmniejszenie zakażeń C. difficile w szpitalach będzie wymagać interwencji ukierunkowanych na przejście od bezobjawowego nosicielstwa do zakażenia.¹

W kontekście rosnącego obciążenia CA-CDI, istnieje potrzeba lepszego zrozumienia, w jaki sposób czynniki społeczno-ekonomiczne mogą wpływać na ryzyko CA-CDI, aby poprawić nie tylko ogólne zrozumienie epidemiologii CDI, ale także opracować potencjalne interwencje, które mogłyby być wdrożone na poziomie społeczności.¹

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Materiały źródłowe

#1 Epidemiology of Clostridium difficile Infection
https://pmc.ncbi.nlm.nih.gov/articles/PMC4128635/
There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st Century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. […] Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. […] Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. […] The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. […] Recent data from the U.S. and Europe suggest the incidence of CDI may have reached a crescendo in recent years and is perhaps beginning to plateau.
#1 Clostridioides difficile infection – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK431054/
Furthermore, data from a 2011 article published by the Centers for Disease Control and Prevention and authored by Lessa et al demonstrated a rise in C difficile incidence across 10 geographic areas in the United States compared to the previous decade, with a higher occurrence observed among females and individuals aged 65 and older. This increase may have been associated with adopting newer, more sensitive C difficile assays, such as nucleic acid amplification tests (NAATs). The data indicated that approximately half a million Americans are infected by C difficile infections annually. Among those infected, about 29,000 patients experienced fatal outcomes within a month of diagnosis, and 15,000 of these deaths were directly linked to C difficile infection. Moreover, approximately 83,000 patients experienced at least a recurrence of C difficile infection, and 29,000 of them succumbed within 30 days of the initial diagnosis. However, more recent data from the United States and Europe show a decreasing prevalence and trend of C difficile infections within healthcare systems, particularly notable in the prevalence of NAP1/B1/027 strain. This decrease may be attributed to a multifaceted approach to reduce unnecessary antimicrobial usage, implement antibiotic stewardship practices, and enhance infection control procedures. Nevertheless, heterogeneity in testing, surveillance, infection prevention, and control practices prevails among hospitals globally and between countries.
#1 Clostridioides difficile Infection (CDI) Surveillance | HAIs | CDC
https://www.cdc.gov/healthcare-associated-infections/php/haic-eip/cdiff.html
In 2022, the incidence rate of CDI increased with age. […] There were 116.1 cases per 100,000 persons in EIP sites in 2022. […] EIP site staff identify cases based on reports of positive C. difficile toxin assay or C. difficile nucleic acid amplification assay from clinical, reference and commercial laboratories serving residents of the surveillance areas. […] A portion of cases subsequently undergo a comprehensive medical record review for clinical information and relevant risk factors. […] EIP site staff collect a convenience sample of stool specimens from incident CDI cases for whom case report forms have been completed.
#1 Insights into the Evolving Epidemiology of Clostridioides difficile Infection and Treatment: A Global Perspective
https://www.mdpi.com/2079-6382/12/7/1141
The incidence of CDI, particularly HA-CDI, appears to have reached a plateau in recent years after increasing steadily over the previous decade. […] In a 2022 Europe-wide survey on the incidence of CDI involving 559 hospitals performed by the European Centre for Disease Prevention and Control (ECDC), the mean incidence of CDI was 3.48 cases per 10,000 patient days. […] While the incidence of HA-CDI has plateaued or declined in North America and Europe, it seems to be rising in Australia. […] Despite the disease burden of C. difficile in low- and middle-income countries, epidemiological data assessing the burden of CDI remain relatively scarce.
#1 Epidemiology of Clostridium difficile Infection
https://pmc.ncbi.nlm.nih.gov/articles/PMC4128635/
Enhanced surveillance methods are needed to monitor the incidence, identify populations at risk, and characterize the molecular epidemiology of strains causing CDI. […] Data from the U.S. and Europe suggest the incidence of CDI may have reached a crescendo in recent years and is leveling off or slightly declining. […] However, the overall incidence of CDI has increased to the point of surpassing rates of methicillin-resistant S. aureus infections in the some areas of the U.S. as the most common cause of healthcare-associated infection. […] The increased burden of CDI places a significant financial constraint on the healthcare system. […] The acute-care direct costs of CDI in the U.S. were estimated to be $4.8 billion in 2008. […] However, the actual cost is likely higher when considering indirect costs associated the management of CDI.
#1 Epidemiology of Clostridium difficile Infection
https://pmc.ncbi.nlm.nih.gov/articles/PMC4128635/
This review discusses the current epidemiology of CDI, including patient risk factors and future challenges. […] While the epidemiology of CDI has changed in the past decade, one of the most notable changes has been the apparent increased incidence among populations in the community who were historically considered to be at low risk, such as healthy peripartum women, children, antibiotic-nave patients, and those with minimal or no recent healthcare exposure. […] Data from North America and Europe suggest that approximately 2027 percent of all CDI cases are community-associated, with an incidence of 2030 per 100,000 population. […] Recently the Centers for Disease Control and Prevention (CDC) launched an active, population-based surveillance for CDI through the Emerging Infections Program.
#1 The burden of CDI in the United States: a multifactorial challenge | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08096-0
Clostridioides difficile infection (CDI) affects approximately 500,000 patients annually in the United States, of these around 30,000 will die. […] While healthcare-associated CDI has declined in recent years, community-associated CDI is on the rise. […] The Centers for Disease Control (CDC) identified CDI as an urgent threat, highlighting the need for immediate and aggressive action to prevent complications and recurrences of this infection. […] The CDC reports that the incidence rate of healthcare-associated CDI (defined as those with onset in a healthcare facility or associated with recent admission to a healthcare facility) is 57.9 cases per 100,000 persons, which represents a sizeable decline in recent years. […] Community-associated CDI, on the other hand, is on the rise, almost doubling in the past decade with an incidence of 63.3 cases per 100,000 persons.
#1 Clostridioides difficile infection in adults: Epidemiology, microbiology, and pathophysiology – UpToDate
https://www.uptodate.com/contents/clostridioides-difficile-infection-in-adults-epidemiology-microbiology-and-pathophysiology
From 2003 to 2006, CDI was observed to be more frequent, severe, refractory to standard therapy, and more likely to relapse than previously described. These observations have been reported throughout North America and Europe and have been attributed, in part, to the emergence of a strain designated as BI, NAP1, or ribotype 027. This strain appears to be more virulent than other strains, which may be attributable to increased toxin production compared with previous strains. Fluoroquinolone use has strongly correlated with the emergence of this strain, and development of fluoroquinolone resistance by outbreak strains appears to have been associated with the increasing frequency of CDI outbreaks. […] Since 2005, CDI due to ribotype 078 has emerged in the Netherlands; the severity is similar to CDI caused by ribotype 027. Ribotype 078 appears to affect a younger patient population, is more frequently community associated, and is genetically similar to porcine isolates. Among 1366 Dutch patients hospitalized between 2006 and 2009, CDI was associated with a 2.5-fold increase in 30-day mortality.
#1 Strategies to prevent Clostridioides difficile infections in acute-care hospitals: 2022 Update | Infection Control & Hospital Epidemiology | Cambridge Core
https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/strategies-to-prevent-clostridioides-difficile-infections-in-acutecare-hospitals-2022-update/575A2A0C9E68BD8535D14B2E337FD0A4
4. More recently, improvements in those previously described trends were observed. US CDI surveillance performed by the CDC Emerging Infections Program noted that since 2014, CDI incidence has leveled off and is perhaps beginning to decrease. However, this trend was marked by a decrease in healthcare-associated (HA) CDI concomitant with an increase in community-associated (CA) CDI. CDI with onset outside the hospital now accounts for 50% of US CDI cases. CDI present on admission to the hospital may increase the risk of CDI for other hospitalized patients. Notably, laboratory-identified healthcare-associated CDI decreased during the first year (i.e., 2020) of the coronavirus disease 2019 (COVID-19) pandemic. […] 5. CDI incidence increased in the early 2000s concomitant with observations of increased CDI severity. Increases in incidence and severity of CDI were associated with the 027/BI/NAP1 strain of C. difficile. However, 027/BI/NAP1 cases have declined significantly in the US, Canada, and Europe. In the US in 2017, the prevalence of the 027/BI/NAP1 strain was 15% of HA-CDI and 6% of CA-CDI cases. Currently, 027/BI/NAP1 is no longer the predominant US strain. Ribotypes 106, 002, and 014/020 have increased in prevalence over the last several years.
#1 Updated Clinical Practice Guidelines for C difficile Infection in Adults
https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults
A number of risk factors for CDI have been identified. The main risk factors for development of CDI are exposure to the healthcare environment, advanced age (65 years or older), and exposure to antibiotics. Receipt of an antimicrobial agent is the most significant modifiable risk factor for initial or recurrent CDI. Although most antibiotics can disrupt normal intestinal gut flora, thereby creating an environment that enables growth and colonization of C difficile, carbapenems, clindamycin, fluoroquinolones, piperacillin-tazobactam, and third- and fourth-generation cephalosporins have been shown to confer the highest risk of infection. Patients are at highest risk for CDI during antimicrobial therapy and within the first month after its discontinuation, and they continue to be at risk for 3 months after completion of therapy.
#1 Burden of Clostridioides difficile infection (CDI) – a systematic review of the epidemiology of primary and recurrent CDI | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-06147-y
Recent estimates put the rate of recurrence at around 15-35% of all CDI cases and data suggests second and subsequent recurrences are common among patients who experience a recurrent episode. […] Risk factors for CDI and recurrent CDI (rCDI) include, among others, increasing age, which is a particularly important factor when exploring possible future trends in CDI incidence. […] The use of antibiotics is another established risk factor for CDI, this is an important consideration given that their use also leads to increased antibiotic resistance. […] The review found no discernible trend in incidence across countries in its scope; some showed stable incidence rates, while others showed decreasing or increasing rates over time. […] Data on incidence of rCDI was reported in 57 studies (30.8% of all included studies). The most common country reported was the US (49.1% of rCDI studies), with smaller numbers of studies available for European countries and Canada, and no studies reporting on Australia.
#1 Epidemiology of Clostridioides difficile infection at a tertiary care facility in Saudi Arabia | Saudi Medical Journal
https://smj.org.sa/content/45/2/188
This study aimed to determine the frequency of risk factors for CDI. […] Therefore, almost one-third of patients had at least 3 risk factors associated with CDI. […] The most prevalent risk factor noted among our study population was the use of acid-reducing drugs (PPIs and histamine-2-receptor antagonists; 75%), and its association with an increased risk of CDI has been established in previous studies. […] A combination of these factors can act as an early predictor of preventive measures in high-risk groups. […] This surveillance data analysis illustrates CDI incidence in the largest military hospital in Saudi Arabia, which can be used as a foundation for future studies on the importance of prevention and control measures to lower CDI incidence.
#1 Updated Clinical Practice Guidelines for C difficile Infection in Adults
https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults
Recurrent CDI may occur after completion of treatment, and approximately 25% of patients with a first episode of CDI will have a recurrent infection. The risk of recurrence increases with the number of CDI episodes, with up to 45% of patients experiencing recurrent CDI after the second episode and more than 60% having a recurrence after three or more episodes. […] A multifactorial approach is recommended for the prevention of CDI. This includes infection prevention measures (e.g., hand hygiene, isolation precautions, contact precautions, and appropriate environmental cleaning and disinfection) as well as implementation of antimicrobial stewardship programs that restrict high-risk antibiotics and focus on minimizing the use and duration of unnecessary antimicrobial agents. […] The updated ACG guidelines state that the use of oral vancomycin as prophylaxis (to prevent recurrence) may be considered in patients with a recent history of CDI who require antibiotic treatment and are at high risk for recurrent infection (i.e., aged 65 years or older or significantly immunocompromised and hospitalized within the previous 3 months for severe CDI); this is a conditional recommendation with a low quality of evidence.
#1 The burden of CDI in the United States: a multifactorial challenge | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08096-0
The incidence of rCDI has increased significantly in recent years and this has been identified as a major public health challenge. […] Data indicate that in the US, recurrence accounts for 75,000 to 175,000 additional cases of CDI per year. […] The breadth of outcomes reported to be associated with CDI is shown in Fig. 1. […] The clinical burden of CDI and rCDI is extensive. […] Studies from four different sources, CDC Emerging Infections Program (EIP), Premier Healthcare Database, National Inpatient Sample and Veterans Administration reported 30-day CDI mortality rates ranging from 6 to 11%. […] Mortality rates associated with all-cause infections increase to 20-37% in the intensive care unit (ICU) setting where patients have more than triple the odds of mortality compared to their non-ICU counterparts.
#1 Clinical Practice Guidelines for the Management of Clostridioides difficile Infection in Adults: 2021 Update by SHEA/IDSA
https://www.idsociety.org/practice-guideline/clostridioides-difficile-2021-focused-update/
This clinical practice guideline is a focused update on management of Clostridioides difficile infection (CDI) in adults specifically addressing the use of fidaxomicin and bezlotoxumab for the treatment of CDI. […] New estimates on the burden of CDI have also been reported by the Centers for Disease Control and Prevention. While the adjusted estimate for total CDI burden nationally decreased by 24% from the previous report, they still estimated 462 100 cases annually and the burden of first CDI recurrences was unchanged. Recurrent CDI remains one of the most important treatment challenges for clinicians, with estimates of 31 300 and 38 500 recurrences for community-associated and healthcare-associated cases, respectively, in 2017. […] The purpose of this guideline is to provide evidence-based guidance on the most effective management of CDI and recurrent CDI in adult patients.
#1 Burden of Clostridioides difficile infection (CDI) – a systematic review of the epidemiology of primary and recurrent CDI | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-06147-y
Recurrence rates for HA-CDI ranged from 3.7 to 64.0%, while CA-CDI patients were reported to have between 3.1 and 28.0% recurrence rates. In all cases the rate of recurrence was lower in community-associated disease than healthcare-associated disease. […] These findings, taken together, underline that CDI is, and will likely remain for the foreseeable future, a disease with a large burden, for which there is a need for effective treatments, both for first episodes and recurrences.
#1 Clostridioides difficile Infection (CDI) Surveillance | HAIs | CDC
https://www.cdc.gov/healthcare-associated-infections/php/haic-eip/cdiff.html
The Clostridioides difficile infection (CDI) Surveillance Program collects data for describing incidence and trends of these infections. […] Public health professionals and healthcare providers can use these data to further public health research and, in turn, health outcomes. […] The Clostridioides difficile infection (CDI) Surveillance Program identifies and monitors: CDI incidence and burden in communities and healthcare settings. […] Trends in disease over time, including changes in strain prevalence. […] To collect this information, trained professionals conduct active population- and laboratory-based surveillance in 10 EIP sites. […] Public health professionals and healthcare administrators can use these data to further research such as: Identifying risk factors for CDI. […] Monitoring effectiveness of prevention strategies.
#1 Clostridioides (Clostridium) difficile infections – Annual Epidemiological Report for 2016â2017
https://www.ecdc.europa.eu/en/publications-data/clostridiodes-difficile-infections-annual-epidemiological-report-2016-2017
On 1 January 2016, ECDC started coordinating the surveillance of Clostridioides (Clostridium) difficile infection (CDI) in acute care hospitals in EU/EEA countries. ECDCs surveillance protocol provides a standardised tool for hospitals to measure and monitor CDI incidence rates, with three surveillance options, i.e. a minimal, a light and an enhanced option, the latter linking case-based epidemiological and microbiological data. […] In 20162017, 24 EU/EEA countries/administrations (UK devolved administrations are counted separately) reported CDI data to ECDC, of which 23 countries had data suitable for analysis. […] For 2017, CDI data were contributed by 21% acute care hospitals in the participating countries/administrations, and 10% of all acute care hospitals in the EU/EEA. […] Overall in 20162017, 72.0% of the CDI cases with case-based data were above 64 years old and the majority (56.4%) were female.
#1 Clostridioides (Clostridium) difficile infections – Annual Epidemiological Report for 2016â2017
https://www.ecdc.europa.eu/en/publications-data/clostridiodes-difficile-infections-annual-epidemiological-report-2016-2017
In 20162017, the crude incidence density of CDI was 3.48 cases per 10 000 patient-days. […] In 20162017, 23 052/37 857 (60.9%) cases were HA CDI. […] In 20162017, 2 439/37 857 (6.4%) CDI cases were reported to be recurrent. […] In 20162017, 12 366/37 857 (32.7%) CDI cases were community-associated (CA CDI), or CDI of unknown association (UA CDI). […] ECDC recommends continual incidence surveillance of CDI for a period of 12 months. If not feasible, ECDC recommends a minimum surveillance period of three months.
#1 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA
https://www.idsociety.org/practice-guideline/clostridium-difficile/
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. […] Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. […] This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management. […] To increase comparability between clinical settings, use available standardized case definitions for surveillance of (1) healthcare facility-onset (HO) CDI; (2) community-onset, healthcare facility-associated (CO-HCFA) CDI; and (3) community-associated (CA) CDI (good practice recommendation).
#1 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA
https://www.idsociety.org/practice-guideline/clostridium-difficile/
At a minimum, conduct surveillance for HO-CDI in all inpatient healthcare facilities to detect elevated rates or outbreaks of CDI within the facility (weak recommendation, low quality of evidence). […] Express the rate of HO-CDI as the number of cases per 10,000 patient-days. Express the CO-HCFA prevalence rate as the number of cases per 1,000 patient admissions (good practice recommendation). […] Stratify data by patient location to target control measures when CDI incidence is above national and/or facility reduction goals or if an outbreak is noted (weak recommendation, low quality of evidence). […] Use the same standardized case definitions (HO, CO-HCFA, CA) and rate expression (cases per 10,000 patient-days for HO, cases per 1,000 patient admissions for CO-HCFA) in pediatric patients as for adults (good practice recommendation). […] Conduct surveillance for HO-CDI for inpatient pediatric facilities but do not include cases 2 years of age (weak recommendation, low quality of evidence). […] Consider surveillance for CA-CDI to detect trends in the community (weak recommendation, low quality of evidence).
#1 Clostridium difficile infection: epidemiology, diagnosis and understanding transmission | Nature Reviews Gastroenterology & Hepatology
https://www.nature.com/articles/nrgastro.2016.25
Clostridium difficile infection (CDI) is a continually evolving global health-care problem. […] Community-onset CDI is increasing and multiple potential reservoirs of infection exist including environmental sources, animals, asymptomatic patients and symptomatic patients. […] Highly discriminatory typing techniques such as whole-genome sequencing and multi-locus variable-number tandem-repeat analysis offer the potential for illuminating previously under-recognized routes of C. difficile transmission. […] Modern technologies, such as whole-genome sequencing and multi-locus variable-number tandem-repeat analysis, are helping to track C. difficile transmission across health-care facilities, countries and continents, offering the potential to illuminate previously under-recognized sources of infection.
#1 Clostridium difficile infection: epidemiology, diagnosis and understanding transmission | Nature Reviews Gastroenterology & Hepatology
https://www.nature.com/articles/nrgastro.2016.25
However, comparison of CDI epidemiology, particularly between countries, is challenging due to wide-ranging approaches to sampling and testing. […] Multistep diagnostic algorithms have been recommended to improve sensitivity and specificity. […] In this Review, we describe the latest advances in the understanding of C. difficile epidemiology, transmission and diagnosis, and discuss the effect of these developments on the clinical management of CDI.
#1 Clostridioides difficile infection – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK431054/
C difficile is the primary causative agent of healthcare-associated post-antibiotic colitis, posing a significant public health challenge due to its transmissibility and associated morbidity and mortality. C difficile is ubiquitous and can colonize the intestines of up to 3% to 5% of healthy individuals without causing any infections. Although transmission of C difficile primarily occurs fecal-orally, it can also stem from various other environmental sources, such as soil. However, the bacterium is more commonly transmitted via contaminated surfaces in hospitals, often in the form of spores. Contaminated surfaces and medical equipment in healthcare facilities can become reservoirs for C difficile spores, potentially transmitting to patients if proper infection prevention and control practices, including appropriate cleaning protocols, are not enforced. The healthcare environment presents a conducive setting for C difficile transmission, owing to the challenge of eradicating spores and the prevalent use of antimicrobials, which fosters the development of C difficile infections.
#1 Longitudinal genomic surveillance of carriage and transmission of Clostridioides difficile in an intensive care unit | Nature Medicine
https://www.nature.com/articles/s41591-023-02549-4
Asymptomatic carriers of C. difficile, defined as persons who carry the C. difficile organism without clinical symptoms indicative of C. difficile infection, could be underappreciated reservoirs of C. difficile within healthcare settings. Asymptomatic carriers are more common in the hospital than symptomatic patients: as many as 29% of high-acuity patients in acute care settings have been shown to carry C. difficile asymptomatically. The risk of transmission from unidentified, asymptomatic carriers may also be higher than from symptomatic patients because carriers can shed spores into the environment, yet they are usually not under the same contact precautions and their rooms may not undergo the same environmental cleaning procedures as patients with CDI. […] However, the risk that asymptomatic carriers of C. difficile pose, both to other patients and to themselves, is incompletely characterized due to a lack of available data collected via detailed longitudinal sampling and high-resolution typing.
#1
https://link.springer.com/article/10.1007/s40121-016-0117-y
Potential sources of exposure in the community are discussed in greater details below, but can be categorised broadly into consumption (ingestion of spores from a contaminated food product), person-to-person contact (transmission from another infected or colonised person), animal-to-person contact (transmission from an infected or colonised domestic or wild animal) and environment-to-person contact (ingestion of spores after exposure to a contaminated environmental source). […] The significance of finding low absolute counts of C. difficile in environmental samples is unclear while the infectious dose remains unknown; detection in any number of sources may or may not be of public health significance. […] One potential source of C. difficile transmission outside of the hospital environment is via animals. Although many clostridia cause disease in both humans and animals, these have not traditionally been considered zoonotic agents.
#1
https://link.springer.com/article/10.1007/s40121-016-0117-y
The potential for C. difficile to act as a foodborne pathogen undoubtedly exists, with several authors examining this potential link. […] Currently, there is insufficient epidemiological evidence linking the consumption of contaminated food to increases of CA-CDI. […] The potential for asymptomatic carriers of C. difficile to shed the organism into the home environment and cause disease in other contacts has been demonstrated, although to date there has been no evidence to support this route as a common mechanism for disease transmission in the community.
#1 Longitudinal genomic surveillance of carriage and transmission of Clostridioides difficile in an intensive care unit | Nature Medicine
https://www.nature.com/articles/s41591-023-02549-4
In summary, applying admission and daily longitudinal screening for C. difficile within a US-based medical ICU, we found that while imported C. difficile strains were rarely transmitted to others, they were associated with significantly increased risk of infection in those who imported them. The low rate of transmission suggests that currently recommended infection prevention strategies are largely successful in preventing C. difficile cross-transmission from asymptomatic carriers in this setting.
#1 Clostridium Difficile Infection (CDI) Surveillance | Yale School of Public Health
https://ysph.yale.edu/emerging-infections-program/projects/haic/c-difficile/
CDI has increased in incidence and severity, becoming the most common pathogen of healthcare-associated infections (HAI) and is a well-known cause of antibiotic associated diarrhea (AAD) and colitis. CDI accounts for 15 to 25% of all episodes of AAD. CDI causes almost half a million infections and estimated 29,300 deaths in the United States each year. About 1 in 6 patients who get CDI will get it again, in the subsequent 2-8 weeks. More than 80% of CDI related deaths occur in people 65 and older. CDI costs the health care system an estimated $3.2 billion annually. Healthcare facilities are strongly recommended to have antibiotic stewardship protocols and infection control practices in place to reduce the incidence of CDI. […] Commonly considered to be hospital-acquired, rates of community-associated (CA) CDI have been increasing and currently make up more than 50% of cases reported. The sources of CA-CDI and the risks for developing CDI in community populations were previously thought to be low risk and are not well defined. Given the emergence and increasing significance of CA-CDI in public health, it is important to understand how poverty may influence the risk of CA-CDIs to improve not only the overall understanding of CDI epidemiology but also develop potential interventions that might be implemented at the community level.
#2 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA
https://www.idsociety.org/practice-guideline/clostridium-difficile/
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. […] Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. […] This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management. […] To increase comparability between clinical settings, use available standardized case definitions for surveillance of (1) healthcare facility-onset (HO) CDI; (2) community-onset, healthcare facility-associated (CO-HCFA) CDI; and (3) community-associated (CA) CDI (good practice recommendation).
#2 The burden of CDI in the United States: a multifactorial challenge | BMC Infectious Diseases | Full Text
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08096-0
Clostridioides difficile infection (CDI) affects approximately 500,000 patients annually in the United States, of these around 30,000 will die. […] While healthcare-associated CDI has declined in recent years, community-associated CDI is on the rise. […] The Centers for Disease Control (CDC) identified CDI as an urgent threat, highlighting the need for immediate and aggressive action to prevent complications and recurrences of this infection. […] The CDC reports that the incidence rate of healthcare-associated CDI (defined as those with onset in a healthcare facility or associated with recent admission to a healthcare facility) is 57.9 cases per 100,000 persons, which represents a sizeable decline in recent years. […] Community-associated CDI, on the other hand, is on the rise, almost doubling in the past decade with an incidence of 63.3 cases per 100,000 persons.
#2 Epidemiology of Clostridium difficile Infection
https://pmc.ncbi.nlm.nih.gov/articles/PMC4128635/
There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st Century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. […] Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. […] Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. […] The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. […] Recent data from the U.S. and Europe suggest the incidence of CDI may have reached a crescendo in recent years and is perhaps beginning to plateau.
#2 Updated Clinical Practice Guidelines for C difficile Infection in Adults
https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults
A number of risk factors for CDI have been identified. The main risk factors for development of CDI are exposure to the healthcare environment, advanced age (65 years or older), and exposure to antibiotics. Receipt of an antimicrobial agent is the most significant modifiable risk factor for initial or recurrent CDI. Although most antibiotics can disrupt normal intestinal gut flora, thereby creating an environment that enables growth and colonization of C difficile, carbapenems, clindamycin, fluoroquinolones, piperacillin-tazobactam, and third- and fourth-generation cephalosporins have been shown to confer the highest risk of infection. Patients are at highest risk for CDI during antimicrobial therapy and within the first month after its discontinuation, and they continue to be at risk for 3 months after completion of therapy.
#2 Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection | Revista de GastroenterologÃa de MÃ©xico
https://www.revistagastroenterologiamexico.org/en-consensus-on-prevention-diagnosis-treatment-articulo-S2255534X19300295
In Mexico, in a retrospective study conducted at 4 hospitals from 3 different cities, the authors reported that of the 487 cases of CDI included in the study, 43 (8.8%) were diagnosed in 2012 and 22 (4.5%) in 2013. […] The increase in more severe cases has been associated with a rise in more virulent strains (hypervirulent strains), such as the NAP1/BI/027 strain, which is the North American pulsed-field gel electrophoresis type 1 (NAP1), restriction endonuclease analysis group BI, and PCR ribotype 027. […] In Mexico, the prevalence of the NAP1/BI/027 strain varies from 28 to 91%. […] The CDI spectrum is variable and ranges from mild diarrhea to severe complications, such as pseudomembranous colitis, toxic megacolon (fulminant colitis), sepsis, and death. […] Colonization by Clostridium difficile is more frequent in patients with a history of hospitalization within the previous 2 months, immunosuppression, and the use of chemotherapy, antibiotics, proton pump inhibitors, or H2 antagonists.
#2 Updated Clinical Practice Guidelines for C difficile Infection in Adults
https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults
Recurrent CDI may occur after completion of treatment, and approximately 25% of patients with a first episode of CDI will have a recurrent infection. The risk of recurrence increases with the number of CDI episodes, with up to 45% of patients experiencing recurrent CDI after the second episode and more than 60% having a recurrence after three or more episodes. […] A multifactorial approach is recommended for the prevention of CDI. This includes infection prevention measures (e.g., hand hygiene, isolation precautions, contact precautions, and appropriate environmental cleaning and disinfection) as well as implementation of antimicrobial stewardship programs that restrict high-risk antibiotics and focus on minimizing the use and duration of unnecessary antimicrobial agents. […] The updated ACG guidelines state that the use of oral vancomycin as prophylaxis (to prevent recurrence) may be considered in patients with a recent history of CDI who require antibiotic treatment and are at high risk for recurrent infection (i.e., aged 65 years or older or significantly immunocompromised and hospitalized within the previous 3 months for severe CDI); this is a conditional recommendation with a low quality of evidence.
#2 Clostridioides difficile Infection (CDI) Surveillance | HAIs | CDC
https://www.cdc.gov/healthcare-associated-infections/php/haic-eip/cdiff.html
The Clostridioides difficile infection (CDI) Surveillance Program collects data for describing incidence and trends of these infections. […] Public health professionals and healthcare providers can use these data to further public health research and, in turn, health outcomes. […] The Clostridioides difficile infection (CDI) Surveillance Program identifies and monitors: CDI incidence and burden in communities and healthcare settings. […] Trends in disease over time, including changes in strain prevalence. […] To collect this information, trained professionals conduct active population- and laboratory-based surveillance in 10 EIP sites. […] Public health professionals and healthcare administrators can use these data to further research such as: Identifying risk factors for CDI. […] Monitoring effectiveness of prevention strategies.
#2 Clostridioides difficile Infection (CDI) Surveillance | HAIs | CDC
https://www.cdc.gov/healthcare-associated-infections/php/haic-eip/cdiff.html
In 2022, the incidence rate of CDI increased with age. […] There were 116.1 cases per 100,000 persons in EIP sites in 2022. […] EIP site staff identify cases based on reports of positive C. difficile toxin assay or C. difficile nucleic acid amplification assay from clinical, reference and commercial laboratories serving residents of the surveillance areas. […] A portion of cases subsequently undergo a comprehensive medical record review for clinical information and relevant risk factors. […] EIP site staff collect a convenience sample of stool specimens from incident CDI cases for whom case report forms have been completed.
#2 Clostridioides (Clostridium) difficile infections – Annual Epidemiological Report for 2016â2017
https://www.ecdc.europa.eu/en/publications-data/clostridiodes-difficile-infections-annual-epidemiological-report-2016-2017
On 1 January 2016, ECDC started coordinating the surveillance of Clostridioides (Clostridium) difficile infection (CDI) in acute care hospitals in EU/EEA countries. ECDCs surveillance protocol provides a standardised tool for hospitals to measure and monitor CDI incidence rates, with three surveillance options, i.e. a minimal, a light and an enhanced option, the latter linking case-based epidemiological and microbiological data. […] In 20162017, 24 EU/EEA countries/administrations (UK devolved administrations are counted separately) reported CDI data to ECDC, of which 23 countries had data suitable for analysis. […] For 2017, CDI data were contributed by 21% acute care hospitals in the participating countries/administrations, and 10% of all acute care hospitals in the EU/EEA. […] Overall in 20162017, 72.0% of the CDI cases with case-based data were above 64 years old and the majority (56.4%) were female.
#2 Clostridioides (Clostridium) difficile infections – Annual Epidemiological Report for 2016â2017
https://www.ecdc.europa.eu/en/publications-data/clostridiodes-difficile-infections-annual-epidemiological-report-2016-2017
In 20162017, the crude incidence density of CDI was 3.48 cases per 10 000 patient-days. […] In 20162017, 23 052/37 857 (60.9%) cases were HA CDI. […] In 20162017, 2 439/37 857 (6.4%) CDI cases were reported to be recurrent. […] In 20162017, 12 366/37 857 (32.7%) CDI cases were community-associated (CA CDI), or CDI of unknown association (UA CDI). […] ECDC recommends continual incidence surveillance of CDI for a period of 12 months. If not feasible, ECDC recommends a minimum surveillance period of three months.
#2 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA
https://www.idsociety.org/practice-guideline/clostridium-difficile/
At a minimum, conduct surveillance for HO-CDI in all inpatient healthcare facilities to detect elevated rates or outbreaks of CDI within the facility (weak recommendation, low quality of evidence). […] Express the rate of HO-CDI as the number of cases per 10,000 patient-days. Express the CO-HCFA prevalence rate as the number of cases per 1,000 patient admissions (good practice recommendation). […] Stratify data by patient location to target control measures when CDI incidence is above national and/or facility reduction goals or if an outbreak is noted (weak recommendation, low quality of evidence). […] Use the same standardized case definitions (HO, CO-HCFA, CA) and rate expression (cases per 10,000 patient-days for HO, cases per 1,000 patient admissions for CO-HCFA) in pediatric patients as for adults (good practice recommendation). […] Conduct surveillance for HO-CDI for inpatient pediatric facilities but do not include cases 2 years of age (weak recommendation, low quality of evidence). […] Consider surveillance for CA-CDI to detect trends in the community (weak recommendation, low quality of evidence).
#2 Clostridium difficile infection: epidemiology, diagnosis and understanding transmission | Nature Reviews Gastroenterology & Hepatology
https://www.nature.com/articles/nrgastro.2016.25
However, comparison of CDI epidemiology, particularly between countries, is challenging due to wide-ranging approaches to sampling and testing. […] Multistep diagnostic algorithms have been recommended to improve sensitivity and specificity. […] In this Review, we describe the latest advances in the understanding of C. difficile epidemiology, transmission and diagnosis, and discuss the effect of these developments on the clinical management of CDI.
#2 Clostridioides difficile infection – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK431054/
C difficile is the primary causative agent of healthcare-associated post-antibiotic colitis, posing a significant public health challenge due to its transmissibility and associated morbidity and mortality. C difficile is ubiquitous and can colonize the intestines of up to 3% to 5% of healthy individuals without causing any infections. Although transmission of C difficile primarily occurs fecal-orally, it can also stem from various other environmental sources, such as soil. However, the bacterium is more commonly transmitted via contaminated surfaces in hospitals, often in the form of spores. Contaminated surfaces and medical equipment in healthcare facilities can become reservoirs for C difficile spores, potentially transmitting to patients if proper infection prevention and control practices, including appropriate cleaning protocols, are not enforced. The healthcare environment presents a conducive setting for C difficile transmission, owing to the challenge of eradicating spores and the prevalent use of antimicrobials, which fosters the development of C difficile infections.
#2 Longitudinal genomic surveillance of carriage and transmission of Clostridioides difficile in an intensive care unit | Nature Medicine
https://www.nature.com/articles/s41591-023-02549-4
Asymptomatic carriers of C. difficile, defined as persons who carry the C. difficile organism without clinical symptoms indicative of C. difficile infection, could be underappreciated reservoirs of C. difficile within healthcare settings. Asymptomatic carriers are more common in the hospital than symptomatic patients: as many as 29% of high-acuity patients in acute care settings have been shown to carry C. difficile asymptomatically. The risk of transmission from unidentified, asymptomatic carriers may also be higher than from symptomatic patients because carriers can shed spores into the environment, yet they are usually not under the same contact precautions and their rooms may not undergo the same environmental cleaning procedures as patients with CDI. […] However, the risk that asymptomatic carriers of C. difficile pose, both to other patients and to themselves, is incompletely characterized due to a lack of available data collected via detailed longitudinal sampling and high-resolution typing.
#2
https://link.springer.com/article/10.1007/s40121-016-0117-y
Potential sources of exposure in the community are discussed in greater details below, but can be categorised broadly into consumption (ingestion of spores from a contaminated food product), person-to-person contact (transmission from another infected or colonised person), animal-to-person contact (transmission from an infected or colonised domestic or wild animal) and environment-to-person contact (ingestion of spores after exposure to a contaminated environmental source). […] The significance of finding low absolute counts of C. difficile in environmental samples is unclear while the infectious dose remains unknown; detection in any number of sources may or may not be of public health significance. […] One potential source of C. difficile transmission outside of the hospital environment is via animals. Although many clostridia cause disease in both humans and animals, these have not traditionally been considered zoonotic agents.
#3 Clostridioides difficile infection – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK431054/
Furthermore, data from a 2011 article published by the Centers for Disease Control and Prevention and authored by Lessa et al demonstrated a rise in C difficile incidence across 10 geographic areas in the United States compared to the previous decade, with a higher occurrence observed among females and individuals aged 65 and older. This increase may have been associated with adopting newer, more sensitive C difficile assays, such as nucleic acid amplification tests (NAATs). The data indicated that approximately half a million Americans are infected by C difficile infections annually. Among those infected, about 29,000 patients experienced fatal outcomes within a month of diagnosis, and 15,000 of these deaths were directly linked to C difficile infection. Moreover, approximately 83,000 patients experienced at least a recurrence of C difficile infection, and 29,000 of them succumbed within 30 days of the initial diagnosis. However, more recent data from the United States and Europe show a decreasing prevalence and trend of C difficile infections within healthcare systems, particularly notable in the prevalence of NAP1/B1/027 strain. This decrease may be attributed to a multifaceted approach to reduce unnecessary antimicrobial usage, implement antibiotic stewardship practices, and enhance infection control procedures. Nevertheless, heterogeneity in testing, surveillance, infection prevention, and control practices prevails among hospitals globally and between countries.
#3 Updated Clinical Practice Guidelines for C difficile Infection in Adults
https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults
A number of risk factors for CDI have been identified. The main risk factors for development of CDI are exposure to the healthcare environment, advanced age (65 years or older), and exposure to antibiotics. Receipt of an antimicrobial agent is the most significant modifiable risk factor for initial or recurrent CDI. Although most antibiotics can disrupt normal intestinal gut flora, thereby creating an environment that enables growth and colonization of C difficile, carbapenems, clindamycin, fluoroquinolones, piperacillin-tazobactam, and third- and fourth-generation cephalosporins have been shown to confer the highest risk of infection. Patients are at highest risk for CDI during antimicrobial therapy and within the first month after its discontinuation, and they continue to be at risk for 3 months after completion of therapy.
#3 Clostridioides difficile Infection (CDI) Surveillance | HAIs | CDC
https://www.cdc.gov/healthcare-associated-infections/php/haic-eip/cdiff.html
The Clostridioides difficile infection (CDI) Surveillance Program collects data for describing incidence and trends of these infections. […] Public health professionals and healthcare providers can use these data to further public health research and, in turn, health outcomes. […] The Clostridioides difficile infection (CDI) Surveillance Program identifies and monitors: CDI incidence and burden in communities and healthcare settings. […] Trends in disease over time, including changes in strain prevalence. […] To collect this information, trained professionals conduct active population- and laboratory-based surveillance in 10 EIP sites. […] Public health professionals and healthcare administrators can use these data to further research such as: Identifying risk factors for CDI. […] Monitoring effectiveness of prevention strategies.
#3 Clostridioides difficile infection – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK431054/
C difficile is the primary causative agent of healthcare-associated post-antibiotic colitis, posing a significant public health challenge due to its transmissibility and associated morbidity and mortality. C difficile is ubiquitous and can colonize the intestines of up to 3% to 5% of healthy individuals without causing any infections. Although transmission of C difficile primarily occurs fecal-orally, it can also stem from various other environmental sources, such as soil. However, the bacterium is more commonly transmitted via contaminated surfaces in hospitals, often in the form of spores. Contaminated surfaces and medical equipment in healthcare facilities can become reservoirs for C difficile spores, potentially transmitting to patients if proper infection prevention and control practices, including appropriate cleaning protocols, are not enforced. The healthcare environment presents a conducive setting for C difficile transmission, owing to the challenge of eradicating spores and the prevalent use of antimicrobials, which fosters the development of C difficile infections.