Clostridium difficile Infection Surveillance

Overview

Clostridium difficile infection (CDI) surveillance is a collaborative project between CDC and the EIP network. Specific collaborators for this project include personnel from the Division of Healthcare Quality Promotion (DHQP, NCEZID), the Division of Foodborne, Waterborne, and Environmental Diseases (DFWED, NCEZID), EIP-funded university-affiliated and state health jurisdiction personnel, and select reference laboratories.

Objectives

  • Determine the population-based incidence of community- and healthcare-associated CDI among participating EIP sites
  • Characterize C. difficile strains that are responsible for CDI in San Francisco County with a focus on strains from community-associated cases
  • Describe the epidemiology of community- and healthcare-associated CDI and generate hypotheses for future research activities using EIP CDI surveillance infrastructure

Main Components

  • Active Surveillance—Stool specimens positive for C. difficile toxin, by assay or PCR, are identified from all healthcare facility-based and outpatient diagnostic clinical laboratories serving San Francisco County residents.
  • Stool Testing—Remnant stool specimens from a subset of cases testing positive for C. difficile toxin are submitted to reference laboratories for culturing, and isolates will be sent to CDC for confirmation and molecular typing.

Surveillance Methods

Case definition: A case of CDI is defined as a stool positive for C. difficile toxin by either enzyme immunoassay or molecular assay (e.g., PCR) on an incident stool specimen from a resident of San Francisco County. Cases that have a positive stool specimen for C. difficile toxin greater than eight weeks after the last positive specimen will be considered as an incident case of CDI. Therefore, for surveillance purposes, an individual may be classified and captured as a new incident case if eight consecutive weeks have elapsed since their last positive test for C. difficile.

Initial case classification: A CDI case will be classified as healthcare facility-onset (HCFO) if the initial specimen that yielded the positive C. difficile toxin result was collected greater than three calendar days after admission to a healthcare facility (e.g., acute care hospital, long-term acute care hospital, long-term care facility). A CDI case will be classified as community-onset (CO) if the initial specimen that yielded the positive C. difficile toxin result was collected in an outpatient setting or within the first three calendar days of a healthcare facility admission.

Secondary case classification: Among CO cases, cases will be further classified either as community-onset healthcare facility-associated (CO-HCFA) or community-associated (CA).

Recurrent episodes: CDI cases that have a positive stool specimen for C. difficile from two to eight weeks of the last positive specimen will be considered as a recurrent episode of CDI.

Duplicate episodes: CDI cases that have a positive stool specimen for C.difficile within two weeks of the last positive specimen will be considered as a duplicate episode.

For more information on the CDI project, please visit the CDC CDI website.

Publications

Garcia EP, Parker E, Nadle J, Winston LG. Clostridium difficile infection (CDI) treatment practices in San Francisco County, 2012. Poster presented at: ID Week 2013. 2nd Annual Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2013 Oct 2-6; San Francisco, CA.

See I, Mu Y, Cohen J, Beldavs Z, Winston L, Dumyati G, Dunn J, Farley MM, Holzbauer S, Lyons C, Johnston H, Phipps E, Wilson L, Anderson L, Lessa FC. Is Clostridium difficile strain type a predictor of disease outcomes? Oral session presented at: Epidemic Intelligence Service (EIS) Conference. 2013 April 22-26; Atlanta, GA.

Wendt J, Cohen J, Mu Y, Dumyati G, Dunn J, Holzbauer S, Winston L, Bamberg W, Meek J, Farley MM, Wilson L, Phipps E, Beldavs Z, Gould C, Lessa FC. Clostridium difficile infection among children: United States, 2010-2011. Oral session presented at: Epidemic Intelligence Service (EIS) Conference. 2013 April 22-26; Atlanta, GA.

Gould CV, Edwards J, Cohen J, McDonald LC, Farley MM, Bamberg W, Wilson L, Dunn J, Winston L, Holzbauer S, Lyons C, Phipps E, Hollick G, Beldavs Z, Gerding D, Lessa FC. Effect of nuclein acid amplification testing on population-based incident rates of Clostridium difficile infection (CDI). Oral session [Abstract #1315] presented at: ID Week 2012. 1st Annual Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2012 Oct 20; San Diego, CA.

Lessa FC, Mu Y, Cohen J, Dumyati G, Farley MM, Winston L, Kast KR, Holzbauer S, Meek J, Beldavs Z, McDonald C, Fridkin S. Evaluation of differences in population-based incidence of Clostridium difficile Infection (CDI) across diverse US geographic locations, 2010. Oral session [Abstract #1314] presented at: ID Week 2012. 1st Annual Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2012 Oct 20; San Diego, CA.

Cohen J, MacCannell D, Clark LA, Bamberg W, Perlmutter R, Dunn J, Nadle J, Holzbauer S, Lyons C, Phipps E, Dumyati G, Beldavs Z, Lessa FC. Changes in Clostridium difficile testing practices and their impact on stool rejection policies across multiple US laboratories. Poster #325 presented at: ID Week 2012. 1st Annual Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2012 Oct 18; San Diego, CA.

Garcia EP, Parker E, Nadle J, Winston LG. Clostridium difficile infections among San Francisco county residents, 2010-2011. Poster #339 presented at: ID Week 2012. 1st Annual Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2012 Oct 16-21; San Diego, CA.

Chitnis A, Holzbauer S, Belflower R, Winston L, Kast KR, Lyons C, Farley MM, Perlmutter R, Dumyait G, Beldavs Z, Dunn J, Gould LH, McDonald C, Lessa FC. Epidemiology of community-associated Clostridium difficile infection (CA-CDI), Emerging Infections Program, 2009-2011. Oral session [Abstract #SXI-3] presented at: 2012 Anaerobe Conference. 2012 June 30; San Francisco, CA.

Additional CDI information

CDC CDI Information: http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html
CDC CDI Tracking: http://www.cdc.gov/hai/eip/clostridium-difficile.html
California Department of Public Health: http://www.cdph.ca.gov/programs/hai/Pages/ClostridiumDifficile(CDiff).aspx

Contact

For questions about CDI surveillance and projects, please contact:

Joelle Nadle, MPH
Project Coordinator, HAIC and MRSA
HAIC@ceip.us