Hospital-based epidemiology: a strategy for ‘dealing with Clostridium difficile’

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Summary

Clostridium difficile-associated diarrhoea (CDAD) remains a major infection control problem. Uncertainty remains over methods of diagnosis and definitions for ascertaining provenance of cases. We undertook a prospective epidemiological study to better ascertain local epidemiology of 275 new cases (general practitioner and hospital) diagnosed in a large teaching hospital in the UK. The highest incidence of cases was found in haematology and critical care and a surprisingly high proportion, 29%, of hospital cases occurred in those aged <65 years. Fifty-five cases were diagnosed within 48 h of admission. Of these, those defined as ‘community-acquired’ varied between 9 and 25 according to various proposed definitions relating to acquisition and onset of diarrhoea. Of 48 community-onset cases, this number varied between 19 and 25, the variability making comparisons between National Health Service (NHS) trusts potentially inaccurate. Cases were followed for 90 days after diagnosis and all cause mortality data obtained. Of 227 cases diagnosed in hospital, 56 (25%) died within 30 days, 29% of whom were aged <65 years. Death certification data were available in 86% of these cases. C. difficile was recorded on 15 (31%) certificates and as a primary cause (1a or 1b) in 8 (17%) cases. Our study shows the value of local epidemiology for planning infection prevention and control strategies within an NHS trust and for contributing to the evidence base for national targets and policies.

Introduction

Well-publicised outbreaks of Clostridium difficile-associated diarrhoea (CDAD), the current Health Protection Agency (HPA) mandatory surveillance data programme, and the recently published Department of Health (DoH) document Clostridium difficile infection: how to deal with the problem all emphasise the continuing problem of CDAD, despite the many national initiatives that have been in place since 2000 to reduce the burden of C. difficile infections.1, 2 The lack of robust data on the true incidence of CDAD, uncertainties over case definitions and methods of diagnosis, the difficulty of defining ‘attributable mortality’, and potential disagreements between National Health Service (NHS) primary care trusts (PCTs) and acute trusts over the source or ‘provenance’ of cases do not provide the ideal environment for the control of CDAD.

In order to address these uncertainties at a local level, we undertook a prospective epidemiological study of all cases of CDAD, both hospitalised patients and general practitioner (GP) cases, diagnosed in our laboratory over a 12 month period. The objective of the study was to provide data that could contribute to more evidence-based planning of the Trust Infection Control and Prevention Programme.

Section snippets

Methods

The study was undertaken in the 1000-bed acute and tertiary care campus of a large teaching hospital in the UK. Each case was identified by the microbiology department following testing performed as a clinical request in patients with diarrhoea over the period 1 October 2006 to 30 September 2007. All inpatient samples were routinely tested for C. difficile toxin in accordance with routine laboratory protocol and GP samples only tested if specifically requested. Samples that initially tested as

Results

A total of 275 new cases of CDAD were diagnosed from laboratory specimens in the 12 month study period, 227 from hospital inpatients, and 48 from GP patients. Table I shows the demographic data for the cases, and the provenance for the hospital-acquired cases.

From data available on the laboratory reporting system, only 16 cases (6%) had laboratory-confirmed CDAD in the 28–90 days preceding the study episode.

In the hospital-acquired cases, the period from hospital admission to CDAD diagnosis

Discussion

In the UK, as in most European and other industrialised countries, the prevention and control of CDAD has become a major objective for hospital infection control teams and healthcare managers. In England, control of CDAD has also become highly politicised, both nationally with government targets, and locally where CDAD rates may influence patient choice of hospitals. When such major decisions are made on infection rate data, it is essential that these data are accurate, comparable, and

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    Copyright © 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.