Clostridium difficile (C. difficile) Surveillance
The Emerging Infections Program (EIP) Clostridium difficile infection (CDI) surveillance is being conducted in all ten EIP sites throughout the United States. Clostridium difficile is an anaerobic, spore-forming, gram positive bacillus that produces two pathogenic toxins: A and B. CDI ranges in severity from mild diarrhea to fulminant colitis and death. The primary risk factor for development of CDI in healthcare settings is recent antimicrobial use. Other risk factors for CDI acquisition in these settings are age greater than 65 years, severe underlying illness, intensive care unit admission, nasogastric intubation, use of Proton Pump Inhibitors and longer duration of hospital stay. Transmission of C. difficile is thought to occur primarily in healthcare facilities, where environmental contamination by C. difficile spores and exposure to antimicrobial drugs are common. No longer limited to healthcare environments, community-associated CDI is the focus of increasing attention. The sources of C. difficile and the risks for developing CDI in community populations, previously thought to be low-risk, are not well defined. The possibility of foodborne transmission from animal source has been suggested. Further studies are needed to understand the implications of isolating C. difficile from meat and potentially from food producing animals. The purpose of the surveillance system is to 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 the population under surveillance with a focus on strains from community-associated cases; and describe the epidemiology of CDI and generate hypotheses for future research activities using EIP CDI surveillance infrastructure.
Goals & 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 the population under surveillance 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.
In Connecticut, CDI laboratory-based surveillance will be conducted for all toxin-positive C. difficile cases that reside in New Haven and Waterbury areas. A list of all positive C. difficile tests will be evaluated to determine individual cases and classify the cases as either Community Onset (Health Care Associated or Community Associated) or Health Care Onset. Each presumptive community-associated case, each community-onset healthcare associated case, and a 10% sample of health-care onset cases will also require full chart review to complete the case report form. Select laboratories will save stool samples on all cases of CDI for further laboratory evaluation including culture and toxinotype testing.
Recent C. difficile Publications
- Trends in incidence of long-term-care facility onset Clostridium difficile infections in 10 US geographic locations during 2011-2015.Guh AY, Mu Y, Baggs J, Winston LG, Bamberg W, Lyons C, Farley MM, Wilson LE, Holzbauer SM, Phipps EC, Beldavs ZG, Kainer MA, Karlsson M, Gerding DN, Dumyati G. Am J Infect Control. 2018 Jul; 2018 Jan 9. PMID: 29329918.
- Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study.Guh AY, Adkins SH, Li Q, Bulens SN, Farley MM, Smith Z, Holzbauer SM, Whitten T, Phipps EC, Hancock EB, Dumyati G, Concannon C, Kainer MA, Rue B, Lyons C, Olson DM, Wilson L, Perlmutter R, Winston LG, Parker E, Bamberg W, Beldavs ZG, Ocampo V, Karlsson M, Gerding DN, McDonald LC. Open Forum Infect Dis. 2017 Fall; 2017 Oct 26. PMID: 29732377.
- Burden of Nursing Home-Onset Clostridium difficile Infection in the United States: Estimates of Incidence and Patient Outcomes.Hunter JC, Mu Y, Dumyati GK, Farley MM, Winston LG, Johnston HL, Meek JI, Perlmutter R, Holzbauer SM, Beldavs ZG, Phipps EC, Dunn JR, Cohen JA, Avillan J, Stone ND, Gerding DN, McDonald LC, Lessa FC. Open Forum Infect Dis. 2016 Jan; 2016 Jan 18. PMID: 26798767.
- Identification of population at risk for future Clostridium difficile infection following hospital discharge to be targeted for vaccine trials.Baggs J, Yousey-Hindes K, Ashley ED, Meek J, Dumyati G, Cohen J, Wise ME, McDonald LC, Lessa FC. Vaccine. 2015 Nov 17; 2015 Oct 9. PMID: 26450660.
- Association Between Outpatient Antibiotic Prescribing Practices and Community-Associated Clostridium difficile Infection.Dantes R, Mu Y, Hicks LA, Cohen J, Bamberg W, Beldavs ZG, Dumyati G, Farley MM, Holzbauer S, Meek J, Phipps E, Wilson L, Winston LG, McDonald LC, Lessa FC. Open Forum Infect Dis. 2015 Sep; 2015 Aug 11. PMID: 26509182.
- Burden of Clostridium difficile infection in the United States.Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, Farley MM, Holzbauer SM, Meek JI, Phipps EC, Wilson LE, Winston LG, Cohen JA, Limbago BM, Fridkin SK, Gerding DN, McDonald LC. N Engl J Med. 2015 Feb 26. PMID: 25714160.
- Determinants of Clostridium difficile Infection Incidence Across Diverse United States Geographic Locations.Lessa FC, Mu Y, Winston LG, Dumyati GK, Farley MM, Beldavs ZG, Kast K, Holzbauer SM, Meek JI, Cohen J, McDonald LC, Fridkin SK. Open Forum Infect Dis. 2014 Sep; 2014 Jul 28. PMID: 25734120.
- NAP1 strain type predicts outcomes from Clostridium difficile infection.See I, Mu Y, Cohen J, Beldavs ZG, Winston LG, Dumyati G, Holzbauer S, Dunn J, Farley MM, Lyons C, Johnston H, Phipps E, Perlmutter R, Anderson L, Gerding DN, Lessa FC. Clin Infect Dis. 2014 May; 2014 Mar 5. PMID: 24604900.
- Clostridium difficile infection among children across diverse US geographic locations.Wendt JM, Cohen JA, Mu Y, Dumyati GK, Dunn JR, Holzbauer SM, Winston LG, Johnston HL, Meek JI, Farley MM, Wilson LE, Phipps EC, Beldavs ZG, Gerding DN, McDonald LC, Gould CV, Lessa FC. Pediatrics. 2014 Apr; 2014 Mar 3. PMID: 24590748.
- Vital signs: improving antibiotic use among hospitalized patients.Fridkin S, Baggs J, Fagan R, Magill S, Pollack LA, Malpiedi P, Slayton R, Khader K, Rubin MA, Jones M, Samore MH, Dumyati G, Dodds-Ashley E, Meek J, Yousey-Hindes K, Jernigan J, Shehab N, Herrera R, McDonald CL, Schneider A, Srinivasan A. MMWR Morb Mortal Wkly Rep. 2014 Mar 7. PMID: 24598596.
Select Publications and Presentations
Antimicrobial Susceptibility of Clostridium difficile Isolates Collected in the United States. Maria Karlsson, Karen Anderson, Ashley Paulick, Davina Campbell, Alice Guh, James K. Rasheed and the CDI Pathogen Working Group. European Congress of Clinical Microbiology and Infectious Diseases (ECCMID). Vienna, Austria. 2017
Evaluation of Factors Associated with the Decrease in Incidence of Long-term Care Facility Onset Clostridium difficile Infections, 2011-2014. . Society for Healthcare Epidemiology of America (SHEA). Atlanta, GA. 2016
Trends in the incidence of Clostridium difficile Infection (CDI) in New Haven County, CT 2011-2015. J Meek, C Lyons, D Olson, J Hadler, Robert Heimer. Northeast Epidemiology Meeting. Saratoga Springs, NY. 2016
Trends in the incidence of Clostridium difficile Infection (CDI) in New Haven County, CT 2011-2015.. Carol Lyons, Danyel Olson, James Meek, James Hadler, Robert Heimer. American Public Health Association. Denver, CO. 2016
Trends in the incidence of Clostridium difficile Infection (CDI) in New Haven County, CT 2011-2015.. Carol Lyons, Danyel Olson, James Meek, James Hadler, Robert Heimer. Connecticut Infectious Disease Society. West Haven, CT. 2016
PREVALENCE OF CLOSTRIDIUM DIFFICILE RIBOTYPE 106 IN THE UNITED STATES, 2012-2014. Paulick, A.; Karlsson, M.; Albrecht, V.; Granade, M.; Guh, A.; Rasheed, J.K.; Limbago, B.; and the EIP CDI Pathogen Group. Anaerobe Conference. Nashville, TN. 2016
MOLECULAR EPIDEMIOLOGY OF CLOSTRIDIUM DIFFICILE ISOLATED IN THE UNITED STATES, 2014. Karlsson M, Paulick A., Albrecht V., Granade M., Guh A., Rasheed J.K., Limbago B. and the EIP CDI Pathogen Group. Anaerobe Conference. Nashville, TN. 2016
Assessment of Risk Factors for Community-Associated Clostridium Difficile Infection (CA-CDI) in a Connecticut Sample. S Greissman, J Hadler, D Weinberger, C Lyons, J Meek. Yale School of Public Health. New Haven, CT. 2015
Risk Factors for Community-Associated Clostridium difficile Infection: a case control study. Susan N. Hocevar, Ghinwa Dumyati, Claire Reisenauer , Rebecca Perlmutter, Erin Parker, Stacy Holzbauer, Corinne M. Davis, Emily Hancock, Carol Lyons, Cliff L. McDonald. ID Week. San Diego, CA. 2015
National estimates of incidence, recurrence, hospitalizatn, and death of nursing home-onset Clostridium difficile infections - United States, 2012. J Hunter, Y Mu, G Dumyati, M Farley, L Winston, H Johnston, J Meek, L Wilson, S Holzbauer, Z Beldavs, E Phipps, J Dunn, J Cohen, J Avillan, N Stone, LC McDonald, F Lessa. Epidemic Intelligence Service Annual Conference. Atlanta, GA. 2015
Area-based Poverty and Community Associated Clostridium difficile Infection in New Haven County, 2011-2013. Ranjit Dhaliwal, Kim Yousey-Hindes, Robert Heimer. Yale School of Public Health. New Haven, CT. 2014
National estimates of incidence, recurrence, hospitalization, and death of nursing home-onset Clostridium difficile infections — United States, 2012. Jennifer C. Hunter, Yi Mu, Ghinwa K. Dumyati, Monica M. Farley, Lisa G. Winston, Helen L. Johnston, James I. Meek, Lucy E. Wilson, Stacy M. Holzbauer, Zintars G. Beldavs, Erin C. Phipps, John R. Dunn, Jessica A. Cohen, Nimalie Stone, L. Clifford McDonald. ID Week. Philadelphia, PA. 2014
Related LinksCenters for Disease Control and Prevention - Clostridium difficile Surveillance
JAMA Internal Medicine Video: Epidemiology of Community-associated C. difficile Infection, 2009-2011
Centers for Disease Control and Prevention: Deadly Diarrhea: C. difficile Causes Immense Suffering, Death
Project Contact Person
Danyel Olson, MPH
Connecticut Emerging Infections Program
One Church Street, 7th floor
New Haven, CT 06510