Considerable efforts have been dedicated to developing strategies to prevent and treat recurrent Clostridium difficile infection (rCDI); however, evidence of the impact of rCDI on patient healthcare utilization and outcomes is limited.

To compare healthcare utilization and 1-year mortality among adults who had rCDI, nonrecurrent CDI, or no CDI.

We performed a nested case-control study among adult Kaiser Foundation Health Plan members from September 1, 2001, through December 31, 2013. We identified CDI through the presence of a positive laboratory test result and divided patients into 3 groups: patients with rCDI, defined as CDI in the 14–57 days after initial CDI; patients with nonrecurrent CDI; and patients who never had CDI. We conducted 3 matched comparisons: (1) rCDI vs no CDI; (2) rCDI vs nonrecurrent CDI; (3) nonrecurrent CDI vs no CDI. We followed patients for 1 year and compared healthcare utilization between groups, after matching patients on age, sex, and comorbidity.

We found that patients with rCDI consistently have substantially higher levels of healthcare utilization in various settings and greater 1-year mortality risk than both patients who had nonrecurrent CDI and patients who never had CDI.

Patients who develop an initial CDI are generally characterized by excess underlying, severe illness and utilization. However, patients with rCDI experience even greater adverse consequences of their disease than patients who do not experience rCDI. Our results further support the need for continued emphasis on identifying and using novel approaches to prevent and treat rCDI.

Infect Control Hosp Epidemiol. 2016;1–8

To report on the prevalence and incidence of Clostridium difficile infection (CDI) from 2009 to 2013 among Veterans Healthcare Administration patients

A retrospective descriptive analysis of data extracted from a large electronic medical record (EMR) database

Data were acquired from VHA healthcare records from 2009 to 2013 that included outpatient clinical visits, long-term care, and hospitalized care as well as pharmacy and laboratory information.

In 2009, there were 10,207 CDI episodes, and in 2013, there were 12,143 CDI episodes, an increase of 19.0%. The overall CDI rate increased by 8.4% from 193 episodes per 100,000 patient years in 2009 to 209 episodes per 100,000 patient years in 2013. Of the CDI episodes identified in 2009, 58% were identified during a hospitalization, and 42% were identified in an outpatient setting. In 2013, 44% of the CDI episodes were identified in an outpatient setting.

This is one of the largest studies that has utilized timely EMR data to describe the current CDI epidemiology at the VHA. Despite an aging population with greater burden of comorbidity than the general US population, our data show that VHA CDI rates stabilized between 2011 and 2013 following increases likely attributable to the introduction of the more sensitive nucleic acid amplification tests (NAATs). The findings in this report will help establish an accurate benchmark against which both current and future VA CDI prevention initiatives can be measured.

Infect. Control Hosp. Epidemiol. 2015;36(9):1038–1045

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

To determine the effect of a pandemic influenza preparedness drill on the rate of influenza vaccination among healthcare workers (HCWs).

Before-after intervention trial.

The University of Iowa Hospitals and Clinics (UIHC), a large, academic medical center, during 2005.

Staff members at UIHC.

UIHC conducted a pandemic influenza preparedness drill that included a goal of vaccinating a large number of HCWs in 6 days without disrupting patient care. Peer vaccination and mobile vaccination teams were used to vaccinate HCWs, educational tools were distributed to encourage HCWs to be vaccinated, and resources were allocated on the basis of daily vaccination reports. Logit models were used to compare vaccination rates achieved during the 2005 vaccination drill with the vaccination rates achieved during the 2003 vaccination campaign.

UIHC vaccinated 54% of HCWs (2,934 of 5,467) who provided direct patient care in 6 days. In 2 additional weeks, this rate increased to 66% (3,625 of 5,467). Overall, 66% of resident physicians (311 of 470) and 63% of nursing staff (1,429 of 2,255) were vaccinated. Vaccination rates in 2005 were significantly higher than the hospitalwide rate of 41% (5,741 of 14, 086) in 2003.

UIHC dramatically increased the influenza vaccination rate among HCWs by conducting a pandemic influenza preparedness drill. Additionally, the drill allowed us to conduct a bioemergency drill in a realistic scenario, use innovative methods for vaccine delivery, and secure administrative support for future influenza vaccination campaigns. Our study demonstrates how a drill can be used to improve vaccination rates significantly.

To determine the risk factors for Clostridium difficile–associated disease (CDAD) in a 25-bed rural hospital and to compare antimicrobial use ratios at the study hospital with those at a large academic medical center.

Case-control study.

A 25-bed rural hospital in Iowa during the period from August 2002 through January 2005.

A total of 17 case patients with CDAD and 34 control patients matched for age (ie, within 10 years of the case patient's age), sex, and admission date (ie, within 2 weeks of the case patient's admission date).

Retrospective medical record review was performed to obtain data on antimicrobial exposures during the 6 weeks before hospital admission for both case and control patients. Exact conditional logistic regression was used for univariable and multivariable analyses. Antimicrobial use ratios were calculated to compare the rates of antimicrobial use for case and control patients at the study hospital with the rates for patients evaluated in a study of CDAD at a nearly 700-bed teaching hospital.

Case patients had a larger cumulative number of days of antimicrobial use (P = .004), and they received a larger total number of antimicrobial agents during hospitalization (P = .001). Antimicrobial use ratios were higher for both case and control patients at the smaller hospital, compared with the larger hospital.

CDAD at a small rural hospital was not associated with exposure to the antimicrobial classes that are typically associated with CDAD, but was instead related to the total number of antimicrobials used to treat patients. The rate of antimicrobial use for case and control patients was about 40% higher at the small rural hospital, compared with the corresponding rates at a large academic medical center.