Hostname: page-component-7b9c58cd5d-hxdxx Total loading time: 0 Render date: 2025-03-16T13:50:50.457Z Has data issue: false hasContentIssue false
  • English
  • Français

Epidemiological Patterns and Hospital Characteristics Associated with Increased Incidence of Clostridium difficile Infection in Quebec, Canada, 1998–2006

Published online by Cambridge University Press:  02 January 2015

Rodica Gilca ,
Bruno Hubert ,
Elise Fortin ,
Colette Gaulin  and
Marc Dionne
Rodica Gilca*
Affiliation:
Direction des Risques Biologiques et de la Santé au Travail, Institut National de Santé Publique du Québec, Quebec, Canada Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada
Bruno Hubert
Affiliation:
Cire des Pays de la Loire, Institut de Veille Sanitaire, Nantes, France
Elise Fortin
Affiliation:
Direction des Risques Biologiques et de la Santé au Travail, Institut National de Santé Publique du Québec, Quebec, Canada
Colette Gaulin
Affiliation:
Bureau de Surveillance et de Vigie Sanitaire, Ministère de la Santé et des Services Sociaux, Quebec, Canada
Marc Dionne
Affiliation:
Direction des Risques Biologiques et de la Santé au Travail, Institut National de Santé Publique du Québec, Quebec, Canada
*
Institut National de Santé Publique du Quebec, 2400 D'Estimauville, Quebec, PQ, CanadaG1E 7G9 ([email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective.

To explore epidemiological patterns of the incidence of Clostridium difficile infection (CDI) and hospital characteristics associated with increased incidence during nonepidemic and epidemic years.

Design.

Retrospective and prospective ecological study.

Setting.

Eighty-three acute care hospitals participating in CDI surveillance in the province of Quebec, Canada.

Methods.

A Serfling-type regression model applied to data obtained from an administrative database (1998-2006) and prospective Quebec CDI surveillance (2004-2006) was used to calculate expected CDI baseline incidence and to detect incidence exceeding the defined epidemic threshold at the provincial and hospital level. Multivariable Poisson regression was used to determine hospital characteristics associated with increased incidence during nonepidemic (1998-2001) and epidemic (2003-2005) periods.

Results.

During the study period (1998-2006), 4,525,847 discharges, including 45,508 with a CDI in any diagnosis field, were reported by 83 hospitals. During 1998-2001, the average Quebec incidence of CDI was 10,304 cases in 1,775,822 discharges (5.8 cases per 1,000 discharges) and presented a pattern of seasonality, with similar patterns at the hospital level for some hospitals. The Quebec epidemic started in October-November 2002 and peaked in March 2004 at 845 cases in 40,852 discharges (20.7 cases per 1,000 discharges). In multivariable analysis, higher incidence was associated with location in Montreal and surrounding regions, greater hospital size, larger proportion of hospitalized elderly patients, longer length of stay, and greater proportion of comorbidities in patients, whereas teaching profile was associated with decreased incidence during both nonepidemic and epidemic periods. The effect of geographical location on incidence was greater during the epidemic.

Conclusion.

Baseline incidence from nonepidemic years and hospital characteristics associated with CDI incidence should be taken into account when estimating the efficacy of interventions.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 31 , Issue 9 , September 2010 , pp. 939 - 947
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. McDonald, LC, Owings, M, Jernigan, DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. EmergInfect Dis 2006;12(3):409–415.Google ScholarPubMed
2. Loo, VG, Poirier, L, Miller, MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353(23):2442–2449.CrossRefGoogle ScholarPubMed
3. Pepin, J, Valiquette, L, Alary, M-E, et al. Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ 2004;171(5):466–472.CrossRefGoogle Scholar
4. Zilberberg, MD, Shorr, AF, Kollef, MH. Increase in adult Clostridium difficile-related hospitalizations and case-fatality rate, United States, 2000-2005. Emerg Infect Dis 2008;14(6):929–931.CrossRefGoogle ScholarPubMed
5. Kuijper, J, Barbut, F, Brazier, JS, et al. Update of Clostridium difficile infection due to PCR ribotype 027 in Europe, 2008. Euro Surveill 2008;13(31):article 5. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId= 18942. Published July 31, 2008. Accessed March 22, 2010.CrossRefGoogle ScholarPubMed
6. McDonald, LC, Killgore, GE, Thompson, A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile . N Engl J Med 2005;353(23):2433–2441.CrossRefGoogle ScholarPubMed
7. Warny, M, Pepin, J, Fang, A, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 2005;366(9491):1079–1084.CrossRefGoogle Scholar
8. Fawley, WN, Underwood, S, Freeman, J, et al. Efficacy of hospital cleaning agents and germicides against epidemic Clostridium difficile strains. Infect Control Hosp Epidemiol 2007;28(8):920–925.CrossRefGoogle ScholarPubMed
9. Thomas, C, Stevenson, M, Riley, TV. Antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea: a systematic review. J Antimi-crob Chemother 2003;51(6):1339–1350.CrossRefGoogle ScholarPubMed
10. McFarland, LV. Renewed interest in a difficult disease: Clostridium difficile infections—epidemiology and current treatment strategies. Curr Opin Gastroenterol 2009;25(1):24–35.CrossRefGoogle Scholar
11. Chandler, RE, Hedberg, K, Cienlak, PR. Clostridium difficile-associated disease in Oregon: increasing incidence and hospital-level risk factors. Infect Control Hosp Epidemiol 2007;28(2):116–122.CrossRefGoogle ScholarPubMed
12. Ricciardi, R, Harriman, K, Baxter, NN, Hartman, LK, Town, RJ, Virnig, BA. Predictors of Clostridium difficile colitis infections in hospitals. Epidemiol Infect 2008;136:913–921.CrossRefGoogle ScholarPubMed
13. Zilberberg, MD. Clostridium difficile-related hospitalizations among US adults, 2006. Emerg Infect Dis 2009;15(1):122–124.CrossRefGoogle ScholarPubMed
14. Archibald, LK, Banerjee, SN, Jarvis, WR. Secular trends in hospital-acquired Clostridium difficile disease in the United States, 1987-2001. J Infect Dis 2004;189(9):1585–1589.CrossRefGoogle ScholarPubMed
15. Jagai, J, Naumova, E. Clostridium difficile-associated disease in the elderly, United States. Emerg Infect Dis 2009;15(2):343–344.CrossRefGoogle ScholarPubMed
16. Muto, CA, Pokrywka, M, Shutt, K, et al. A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol 2005;26(3):273–280.CrossRefGoogle Scholar
17. Muto, CA, Blank, MK, Marsh, JW, et al. Control of an outbreak of infection with the hypervirulent Clostridium difficile BI strain in a university hospital using a comprehensive “bundle” approach. Clin Infect Dis 2007;45(10):1266–1273.CrossRefGoogle Scholar
18. Hubert, B, Loo, VG, Bourgault, AM, et al. A portrait of the geographic dissemination of the Clostridium difficile North American pulsed-field strain and the epidemiology of Clostridium difficile-associated disease in Quebec. Clin Infect Dis 2007;44(2):238–244.CrossRefGoogle ScholarPubMed
19. Gilca, R, Loo, VG, Hubert, B, et al. Changing incidence of C. Difficile-associated diarrhea in Quebec is associated with changing strain prevalence. In: Abstracts of the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology;2007:336. Abstract K-603.Google Scholar
20. Charlson, ME, Pompei, P, Ales, KL, MacKenzie, CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–383.CrossRefGoogle ScholarPubMed
21. Deyo, RA, Cherkin, DC, Ciol, MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45(6):613–619.CrossRefGoogle ScholarPubMed
22. Quebec Ministry of Health and Social Services Web site. http://www.msss.gouv.qc.ca/. Accessed March 22, 2010.Google Scholar
23. Gilca, R, Fortin, E, Frenette, C, Gourdeau, M. Surveillance des diarrhees associees à Clostridium difficile au Québec: bilan du 22 août 2004 au 18 août 2007. Institut national de santé publique du Québec Web site. http://www.inspq.qc.ca/pdf/publications/745_Cdifficile_bilan2004-2007.pdf. Published 2008. Accessed March 22, 2010.Google Scholar
24. Serfling, RE. Methods for current statistical analysis of excess pneumonia-influenza deaths. Public Health Rep 1963;78(6):494–506.CrossRefGoogle Scholar
25. Simonsen, L, Clarke, MJ, Williamson, GD, Stroup, DF, Arden, NH, Schonberger, LB. The impact of influenza epidemics on mortality: introducing a severity index. Am J Public Health 1997;87(12):1944–1950.CrossRefGoogle ScholarPubMed
26. Alfa, MJ, Du, T, Beda, G. Survey of incidence of Clostridium difficile infection in Canadian hospitals and diagnostic approaches. J Clin Microbiol 1998;36(7):2076–2080.CrossRefGoogle ScholarPubMed
27. Hyland, M, Ofner-Agostini, M, Miller, M, et al. N-CDAD in Canada: results of the Canadian nosocomial infection surveillance program 1997 N-CDAD prevalence surveillance project. Can J Infect Dis 2001;12(2):81–88.Google ScholarPubMed
28. Tan, ET, Robertson, CA, Brynildsen, S, Bresnitz, E, Tan, C, McDonald, C. Clostridium difficile-associated disease in New Jersey hospitals, 2000-2004. Emerg Infect Dis 2007;13(3):498–500.CrossRefGoogle ScholarPubMed
29. Ricciardi, R, Rothenberger, DA, Madoff, RD, Baxter, NN. Increasing prevalence and severity of Clostridium difficile colitis in hospitalized patients in the United States. Arch Surg 2007;142(7):624–631; discussion 631.CrossRefGoogle ScholarPubMed
30. Dubberke, ER, Reske, KA, Yan, Y, Olsen, MA, McDonald, LC, Fraser, VJ. Clostridium difficile-associated disease in a setting of endemicity: identification of novel risk factors. Clin Infect Dis 2007;45(12):1543–1549.CrossRefGoogle Scholar
31. Goorhuis, A, van Dissel, JT, Kuijper, EJ. Novel risk factors for Clostridium difficile-associated disease in a setting of endemicity? Clin Infect Dis 2008;47(3):429–430; author reply 430-431.CrossRefGoogle Scholar
32. Dubberke, ER, Gending, DN, Classen, D, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S81–S92.CrossRefGoogle ScholarPubMed
33. Polgreen, PM, Yang, M, Bohnett, LC, Cavanaugh, JE. A time-series analysis of Clostridium difficile and its seasonal association with influenza. Infect Control Hosp Epidemiol 2010;31(4):382–387.CrossRefGoogle ScholarPubMed
34. Valiquette, L, Cossette, B, Garant, MP, Diab, H, Pepin, J. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007;45(suppl 2):S112–S121.CrossRefGoogle ScholarPubMed
35. Weiss, K, Boisvert, A, Chagnon, M, et al. Multipronged intervention strategy to control an outbreak of Clostridium difficile infection (CDI) and its impact on the rates of CDI from 2002 to 2007. Infect Control Hosp Epidemiol 2009;30(2):156–162.CrossRefGoogle ScholarPubMed
36. MacCannell, DR, Louie, TJ, Gregson, DB, et al. Molecular analysis of Clostridium difficile PCR ribotype 027 isolates from eastern and western Canada. J Clin Microbiol 2006;44(6):2147–2152.CrossRefGoogle ScholarPubMed
37. Hubert, B, Gilca, R. Use administrative databases with caution. CMAJ 2009;180(1):78; author reply 78-79.CrossRefGoogle ScholarPubMed
38. Dubberke, ER, Reske, KA, McDonald, LC, Fraser, VJ. ICD-9 codes and surveillance for Clostridium difficile-associated disease. Emerg Infect Dis 2006;12(10);1576–1579.CrossRefGoogle ScholarPubMed
39. Scheurer, DB, Hicks, LS, Cook, EF, Schnipper, JL. Accuracy of ICD-9 coding for Clostridium difficile infections: a retrospective cohort. Epidemiol Infect 2007;135(6):1010–1013.CrossRefGoogle ScholarPubMed