Skip to main content Accessibility help

Epidemiology and Healthcare Costs of Incident Clostridium difficile Infections Identified in the Outpatient Healthcare Setting

  • Jennifer L. Kuntz (a1), Eric S. Johnson (a1), Marsha A. Raebel (a2) (a3), Amanda F. Petrik (a1), Xiuhai Yang (a1), Micah L. Thorp (a1), Steven J. Spindel (a4), Nancy Neil (a5) (a6) and David H. Smith (a1)...



To describe the epidemiology and healthcare costs of Clostridium difficile infection (CDI) identified in the outpatient setting.


Population-based, retrospective cohort study.


Kaiser Permanente Colorado and Kaiser Permanente Northwest members between June 1, 2005, and September 30, 2008.


We identified persons with incident CDI and classified CDI by whether it was identified in the outpatient or inpatient healthcare setting. We collected information about baseline variables and follow-up healthcare utilization, costs, and outcomes among patients with CDI. We compared characteristics of patients with CDI identified in the outpatient versus inpatient setting.


We identified 3,067 incident CDIs; 56% were identified in the outpatient setting. Few strong, independent predictors of diagnostic setting were identified, although a previous stay in a nonacute healthcare institution (odds ratio [OR], 1.45 [95% confidence interval (CI), 1.13-1.86]) was statistically associated with outpatient-identified CDI, as was age from 50 to 59 years (OR, 1.64 [95% CI, 1.18-2.29]), 60 to 69 years (OR, 1.37 [95% CI, 1.03-1.82]), and 70 to 79 years (OR, 1.36 [95% CI, 1.06-1.74]), when compared with persons aged 80-89 years.


We found that more than one-half of incident CDIs in this population were identified in the outpatient setting. Patients with outpatient-identified CDI were younger with fewer comorbidities, although they frequently had previous exposure to healthcare. These data suggest that practitioners should be aware of CDI and obtain appropriate diagnostic testing on outpatients with CDI symptoms.

Infect Control Hosp Epidemiol 2012;33(10):1031-1038


Corresponding author

Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227 (


Hide All
1.Elixhauser, A, Jhung, M. Clostridium difficile-Associated Disease in U.S. Hospitals, 1993–2005. Statistical brief 50. Rockville, MD: Healthcare Cost and Utilization Project, 2006.
2.Gerding, DN, Johnson, S, Peterson, LR, Mulligan, ME, Silva, J Jr. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol 1995;16:459477.
3.Bignardi, GE. Risk factors for Clostridium difficile infection. J Hosp Infect 1998;40:115.
4.Blondeau, JM. What have we learned about antimicrobial use and the risks for Clostridium difficile-associated diarrhoea? J Antimicrob Chemother 2009;63:238242.
5.Kuntz, JL, Chrischilles, EA, Pendergast, JF, Herwaldt, LA, Polgreen, PM. Incidence of and risk factors for community-associated Clostridium difficile infection: a nested case-control study. BMC Infect Dis 2011;11:194.
6.Hirshon, JM, Thompson, AD, Limbago, B, et al.Clostridium difficile infection in outpatients, Maryland and Connecticut, USA, 2002–2007. Emerg Infect Dis 2011;17:19461949.
7.Fellmeth, G, Yarlagadda, S, Iyer, S. Epidemiology of community-onset Clostridium difficile infection in a community in the south of England. J Infect Public Health 2010;3:118123.
8.Bauer, MP, Goorhuis, A, Koster, T, et al.Community-onset Clostridium difficile-associated diarrhoea not associated with antibiotic usage: two case reports with review of the changing epidemiology of Clostridium difficile-associated diarrhoea. Neth J Med 2008;66:207211.
9.Centers for Disease Control and Prevention. Surveillance for community-associated Clostridium difficile. Connecticut, 2006. MMWR Morb Mortal Wkly Rep 2008;57:340343.
10.Centers for Disease Control and Prevention. Severe Clostridium difficile-associated disease in populations previously at low risk: four states, 2005. MMWR Morb Mortal Wkly Rep 2005;54:12011205.
11.Hirschhorn, LR, Trnka, Y, Onderdonk, A, Lee, ML, Platt, R. Epidemiology of community-acquired Clostridium difficile-associated diarrhea. J Infect Dis 1994;169:127133.
12.McDonald, LC, Coignard, B, Dubberke, E, et al.Recommendations for surveillance of Clostridium difficile-associated disease. Infect Control Hosp Epidemiol 2007;28:140145.
13.Dubberke, ER, Reske, KA, McDonald, LC, Fraser, VJ. ICD-9 codes and surveillance for Clostridium difficile-associated disease. Emerg Infect Dis 2006;12:15761579.
14.Scheurer, DB, Hicks, LS, Cook, EF, Schnipper, JL. Accuracy of ICD-9 coding for Clostridium difficile infections: a retrospective cohort. Epidemiol Infect 2007;135:10101013.
15.Levey, AS, Coresh, J, Balk, E, et al.National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003;139:137147.
16.Harrell, FE. Regression Modeling Strategies. New York: Springer, 2001.
17.Hornbrook, M, Goodman, MJ. Adjusting health benefit contributions to reflect risks. In: Hornbrook, M, ed. Risk Based Contributions to Private Health Insurance. Greenwich, CT: JAI, 1991: 41.
18.Palmore, TN, Sohn, S, Malak, SF, Eagan, J, Sepkowitz, KA. Risk factors for acquisition of Clostridium difficile-associated diarrhea among outpatients at a cancer hospital. Infect Control Hosp Epidemiol 2005;26:680684.
19.Dubberke, ER, Reske, KA, Olsen, MA, McDonald, LC, Fraser, VJ. Short- and long-term attributable costs of Clostridium difficile-associated disease in nonsurgical inpatients. Clin Infect Dis 2008;46:497504.

Epidemiology and Healthcare Costs of Incident Clostridium difficile Infections Identified in the Outpatient Healthcare Setting

  • Jennifer L. Kuntz (a1), Eric S. Johnson (a1), Marsha A. Raebel (a2) (a3), Amanda F. Petrik (a1), Xiuhai Yang (a1), Micah L. Thorp (a1), Steven J. Spindel (a4), Nancy Neil (a5) (a6) and David H. Smith (a1)...


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed