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Original Investigation |

Epidemiology of Community-Associated Clostridium difficile Infection, 2009 Through 2011

Amit S. Chitnis, MD, MPH1,2; Stacy M. Holzbauer, DVM, MPH3,4; Ruth M. Belflower, RN, MPH1,5; Lisa G. Winston, MD6; Wendy M. Bamberg, MD7; Carol Lyons, MPH8; Monica M. Farley, MD9,10; Ghinwa K. Dumyati, MD11; Lucy E. Wilson, MD, ScM12; Zintars G. Beldavs, MS13; John R. Dunn, DVM, PhD14; L. Hannah Gould, PhD, MS15; Duncan R. MacCannell, PhD1; Dale N. Gerding, MD16,17; L. Clifford McDonald, MD1; Fernanda C. Lessa, MD, MPH1
[+] Author Affiliations
1Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
2Epidemic Intelligence Service, Office of Workforce and Career Development, Atlanta, Georgia
3Office of Public Health Preparedness and Response, Career Epidemiology Field Office Program, Centers for Disease Control and Prevention, Atlanta, Georgia
4Centers for Disease Control and Prevention Career Epidemiology Field Officer Assigned to Minnesota Department of Health, St Paul
5Atlanta Research and Education Foundation, Atlanta, Georgia
6Division of Infectious Diseases, Department of Medicine, University of California, San Francisco School of Medicine
7Colorado Department of Public Health and Environment, Denver
8Emerging Infections Program, Yale University School of Medicine, New Haven, Connecticut
9Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
10Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
11Division of Infectious Diseases, Department of Medicine, University of Rochester School of Medicine, Rochester, New York
12Maryland Department of Health and Mental Hygiene, Baltimore
13Oregon Health Authority, Public Health Division, Portland
14Tennessee Department of Health, Nashville
15Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
16Division of Infectious Diseases, Department of Medicine, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
17Hines Veterans Affairs Hospital, Hines, Illinois
JAMA Intern Med. 2013;173(14):1359-1367. doi:10.1001/jamainternmed.2013.7056.
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Importance  Clostridium difficile infection (CDI) has been increasingly reported among healthy individuals in the community. Recent data suggest that community-associated CDI represents one-third of all C difficile cases. The epidemiology and potential sources of C difficile in the community are not fully understood.

Objectives  To determine epidemiological and clinical characteristics of community-associated CDI and to explore potential sources of C difficile acquisition in the community.

Design and Setting  Active population-based and laboratory-based CDI surveillance in 8 US states.

Participants  Medical records were reviewed and interviews performed to assess outpatient, household, and food exposures among patients with community-associated CDI (ie, toxin or molecular assay positive for C difficile and no overnight stay in a health care facility within 12 weeks). Molecular characterization of C difficile isolates was performed. Outpatient health care exposure in the prior 12 weeks among patients with community-associated CDI was a priori categorized into the following 3 levels: no exposure, low-level exposure (ie, outpatient visit with physician or dentist), or high-level exposure (ie, surgery, dialysis, emergency or urgent care visit, inpatient care with no overnight stay, or health care personnel with direct patient care).

Main Outcomes and Measures  Prevalence of outpatient health care exposure among patients with community-associated CDI and identification of potential sources of C difficile by level of outpatient health care exposure.

Results  Of 984 patients with community-associated CDI, 353 (35.9%) did not receive antibiotics, 177 (18.0%) had no outpatient health care exposure, and 400 (40.7%) had low-level outpatient health care exposure. Thirty-one percent of patients without antibiotic exposure received proton pump inhibitors. Patients having CDI with no or low-level outpatient health care exposure were more likely to be exposed to infants younger than 1 year (P = .04) and to household members with active CDI (P = .05) compared with those having high-level outpatient health care exposure. No association between food exposure or animal exposure and level of outpatient health care exposure was observed. North American pulsed-field gel electrophoresis (NAP) 1 was the most common (21.7%) strain isolated; NAP7 and NAP8 were uncommon (6.7%).

Conclusions and Relevance  Most patients with community-associated CDI had recent outpatient health care exposure, and up to 36% would not be prevented by reduction of antibiotic use only. Our data support evaluation of additional strategies, including further examination of C difficile transmission in outpatient and household settings and reduction of proton pump inhibitor use.

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Ascertainment and Classification

Ascertainment and classification of patients with community-associated Clostridium difficile infection, 2009 through 2011.

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