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Original Investigation |

Effect of Detecting and Isolating Clostridium difficile Carriers at Hospital Admission on the Incidence of C difficile Infections A Quasi-Experimental Controlled Study

Yves Longtin, MD1,2; Bianka Paquet-Bolduc, RN, MPA3; Rodica Gilca, MD, PhD4,5,6; Christophe Garenc, PhD4,7; Elise Fortin, PhD4; Jean Longtin, MD5,6,7,8; Sylvie Trottier, MD, MSc5,6,7,9; Philippe Gervais, MD5,6,9; Jean-François Roussy, MD5,6,9; Simon Lévesque, PhD8; Debby Ben-David, MD10; Isabelle Cloutier, BPharm11; Vivian G. Loo, MD2,12
[+] Author Affiliations
1Infection Prevention and Control Unit, Jewish General Hospital Sir Mortimer B. Davis, Montreal, Québec, Canada
2Faculty of Medicine, McGill University, Montreal, Québec, Canada
3Infection Control Unit, Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec City, Canada
4Institut National de Santé Publique du Québec, Québec City, Canada
5Centre Hospitalier Universitaire de Québec, Québec City, Canada
6Faculty of Medicine, Université Laval, Québec City, Québec, Canada
7Centre de Recherche en Infectiologie de l’Université Laval, Québec City, Québec, Canada
8Laboratoire de Santé Publique du Québec, Institut National de Santé Publique du Québec, Sainte-Anne-de-Bellevue, Canada
9Department of Infectious Diseases, Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec City, Canada
10Infectious Diseases Unit, Chaim Sheba Medical Center, Tel HaShomer, Israel
11Department of Pharmacy, Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec City, Canada
12Division of Infectious Diseases, McGill University Health Centre, Montreal, Québec, Canada
JAMA Intern Med. 2016;176(6):796-804. doi:10.1001/jamainternmed.2016.0177.
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Importance  Clostridium difficile infection (CDI) is a major cause of health care–associated infection worldwide, and new preventive strategies are urgently needed. Current control measures do not target asymptomatic carriers, despite evidence that they can contaminate the hospital environment and health care workers’ hands and potentially transmit C difficile to other patients.

Objective  To investigate the effect of detecting and isolating C difficile asymptomatic carriers at hospital admission on the incidence of health care–associated CDI (HA-CDI).

Design, Setting, and Participants  We performed a controlled quasi-experimental study between November 19, 2013, and March 7, 2015, in a Canadian acute care facility. Admission screening was conducted by detecting the tcdB gene by polymerase chain reaction on a rectal swab. Carriers were placed under contact isolation precautions during their hospitalization.

Main Outcomes and Measures  Changes in HA-CDI incidence level and trend during the intervention period (17 periods of 4 weeks each) were compared with the preintervention control period (120 periods of 4 weeks each) by segmented regression analysis and autoregressive integrated moving average (ARIMA) modeling. Concomitant changes in the aggregated HA-CDI incidence at other institutions in Québec City, Québec (n = 6) and the province of Québec (n = 94) were also examined.

Results  Overall, 7599 of 8218 (92.5%) eligible patients were screened, among whom 368 (4.8%) were identified as C difficile carriers. During the intervention, 38 patients (3.0 per 10 000 patient-days) developed an HA-CDI compared with 416 patients (6.9 per 10 000 patient-days) during the preintervention control period (P < .001). There was no immediate change in the level of HA-CDIs on implementation (P = .92), but there was a significant decrease in trend over time of 7% per 4-week period (rate ratio, 0.93; 95% CI, 0.87-0.99 per period; P = .02). ARIMA modeling also detected a significant effect of the intervention, represented by a gradual progressive decrease in the HA-CDI time series by an overall magnitude of 7.2 HA-CDIs per 10 000 patient-days. We estimated that the intervention had prevented 63 of the 101 (62.4%) expected cases. By contrast, no significant decrease in HA-CDI rates occurred in the control groups.

Conclusions and Relevance  Detecting and isolating C difficile carriers was associated with a significant decrease in the incidence of HA-CDI. If confirmed in subsequent studies, this strategy could help prevent HA-CDI.

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Figure 1.
Incidence of Health Care–Associated Clostridium difficile Infection (CDI) per 4-Week Period According to Standardized Surveillance Definitions, August 2004 to March 2015, Québec Heart and Lung Institute, Québec City, Canada

An intervention consisting of screening and isolation of C difficile asymptomatic carriers was introduced on November 19, 2013. The institution is subjected to a government-imposed threshold of 9.0 per 10 000 patient-days (dashed black line). The expected CDI rate during the intervention using an autoregressive integrated moving average (ARIMA) prediction model is shown (dashed blue line).

Graphic Jump Location
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Figure 2.
Incidence of Health Care–Associated Clostridium difficile Infection (CDI) per 4-Week Period at the Québec Heart and Lung Institute and in 2 Control Groups, August 2004 to March 2015

Incidence rates in other institutions in Québec City, Québec (upper graph) and in the province of Québec (lower graph) are shown as comparators.

Graphic Jump Location

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