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Multicenter Study of the Impact of Community-Onset Clostridium difficile Infection on Surveillance for C. difficile Infection

  • Erik R. Dubberke (a1), Anne M. Butler (a1), Bala Hota (a2), Yosef M. Khan (a3), Julie E. Mangino (a3), Jeanmarie Mayer (a4), Kyle J. Popovich (a2), Kurt B. Stevenson (a3), Deborah S. Yokoe (a5), L. Clifford McDonald (a6), John Jernigan (a6), Victoria J. Fraser (a1) and Prevention Epicenters Program from the Centers for Disease Control and Prevention...



To evaluate the impact of cases of community-onset, healthcare facility (HCF)-associated Clostridium difficile infection (CDI) on the incidence and outbreak detection of CDI.


A retrospective multicenter cohort study.


Five university-affiliated, acute care HCFs in the United States.


We collected data (including results of C. difficile toxin assays of stool samples) on all of the adult patients admitted to the 5 hospitals during the period from July I, 2000, through June 30, 2006. CDI cases were classified as HCF-onset if they were diagnosed more than 48 hours after admission or as community-onset, HCF-associated if they were diagnosed within 48 hours after admission and if the patient had recently been discharged from the HCF. Four surveillance definitions were compared: cases of HCF-onset CDI only (hereafter referred to as HCF-onset CDI) and cases of HCF-onset and community-onset, HCF-associated CDI diagnosed within 30, 60, and 90 days after the last discharge from the study hospital (hereafter referred to as 30-day, 60-day, and 90-day CDI, respectively). Monthly CDI rates were compared. Control charts were used to identify potential CDI outbreaks.


The rate of 30-day CDI was significantly higher than the rate of HCF-onset CDI at 2 HCFs (P < .01 ). The rates of 30-day CDI were not statistically significantly different from the rates of 60-day or 90-day CDI at any HCF. The correlations between each HCF's monthly rates of HCF-onset CDI and 30-day CDI were almost perfect (ρ range, 0.94-0.99; P < .001). Overall, 12 time points had a CDI rate that was more than 3 standard deviations above the mean, including 11 time points identified using the definition for HCF-onset CDI and 9 time points identified using the definition for 30-day CDI, with discordant results at 4 time points (k = 0.794; P < .001).


Tracking cases of both community-onset and HCF-onset, HCF-associated CDI captures significantly more CDI cases, but surveillance of HCF-onset, HCF-associated CDI alone is sufficient to detect an outbreak.


Corresponding author

Division of Infectious Diseases, Washington University School of Medicine, Box 8051, 660 South Euclid, St. Louis, MO 63110 (


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