2019 Annual Report for the Emerging Infections Program for Clostridioides difficile Infection

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Summary

2019 Annual Report Print Version [PDF – 8 Pages]

Surveillance data from 2019 represent the ninth year of population-based surveillance for CDI conducted among all 10 Emerging Infections Program sites. The crude overall incidence rate of CDI in 2019 was 121.2 cases per 100,000 persons, with a higher incidence of community associated cases (63.2 cases per 100,000 persons) compared with healthcare-associated cases (57.9 cases per 100,000 persons). The incidence rate of CDI increased with age and was higher in women than in men and higher in White persons than in persons of other races.

Underlying conditions were commonly reported among CDI cases, with 39 percent having a Charlson comorbidity index of ≥2. Antibiotic use in the prior 12 weeks was reported for 60 percent of CDI cases. Eighty-three percent of CDI cases were treated, with vancomycin being the most common treatment given. CDI-related complications, such as toxic megacolon and ileus, were rare.

Surveillance Catchment Areas

California (1 county San Francisco area), Colorado (5 county Denver area); Connecticut (1 county New Haven area); Georgia (8 county Atlanta area); Maryland (9 eastern shore and 2 western counties); Minnesota (5 counties); New Mexico (1 county Albuquerque area); New
York (1 county Rochester area); Oregon (1 rural county); and Tennessee (1 county Nashville area).

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Population

The surveillance area represents 12,058,331 persons.
Source: U.S. Census Bureau, Population Division, Vintage 2019 Special Tabulation.

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Case Definition

An incident case of Clostridioides difficile infection (CDI) was defined as a C. difficile-positive stool test (toxin or molecular assay) from a person ≥1 year old with no positive test in the prior 8 weeks.

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Methods

Case finding was active, laboratory-based, and population-based. Laboratories serving the surveillance catchment areas reported all positive C. difficile tests to EIP staff and were routinely audited to ensure complete case ascertainment.

An initial chart review was performed on all CDI cases in eight EIP sites and on all pediatric cases and a 1/3 random sample of cases age 18 years and older in the two remaining EIP sites with the largest surveillance catchment areas (CO and GA). A subsequent comprehensive chart review was performed on all community-associated cases and a subset of healthcare facility onset cases.

A standardized case report form (CRF) was completed for each incident case through review of medical records. Inpatient and outpatient medical records were reviewed for information on patient demographics, clinical syndrome, outcome of illness, and relevant healthcare exposures.

A convenience sample of stool specimens or swabs were sent to reference laboratories for C. difficile isolation. Recovered isolates were sent to CDC for molecular typing and characterization.

A CDI case was classified as community-associated (CA) if the C. difficile-positive stool specimen was collected on an outpatient basis or within 3 days after hospital admission in a person with no documented overnight stay in a healthcare facility in the preceding 12 weeks. All CDI cases that do not meet the aforementioned criteria were classified as healthcare-associated (HA). HA cases with disease onset outside of a healthcare facility but with documented overnight stay in a healthcare facility in the preceding 12 weeks were classified as community-onset, healthcare facility associated (CO-HCFA). HA cases with disease onset in a healthcare facility were classified as healthcare-facility onset (HCFO). HCFO cases were further classified into hospital onset or long-term care facility onset. Incidence rates were calculated using US Census population estimates.

CDI surveillance data undergo regular data cleaning to ensure accuracy and completeness. Patients with complete case report form data as of 10/12/2021 were included in this analysis. Because data can be updated as needed, analyses of datasets generated on a different date may yield slightly different results.

14612 cases in 10 sites, 5001 not sampled (CO and GA), 9611 selected for medical record review, 1965 with partial CRF 147 without medical record access,
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Results
Table 1 – Reported Number of CDI Cases and Crude Incidence by Sex, Age Group, Race, and Epidemiologic Classification Among the 10 EIP Sites
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Sex Population ≥1 Year of Age Community Associated CDIa No.c Community Associated CDIa Incidenceb Healthcare Associated CDIa No.c Healthcare Associated CDIa Incidenceb All CDI No.c All CDI Incidenceb
Male 5,900,745 2947 49.9 3276 55.5 6223 105.5
Female 6,157,586 4681 76.0 3708 60.2 8389 136.2
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Age Group Population ≥1 Year of Age Community Associated CDIa No.c Community Associated CDIa Incidenceb Healthcare Associated CDIa No.c Healthcare Associated CDIa Incidenceb All CDI No.c All CDI Incidenceb
1-17 years 2,514,825 650 25.8 225 8.9 875 34.8
18-44 years 4,732,015 1912 40.4 849 17.9 2761 58.3
45-49 years 799,563 422 52.7 325 40.7 747 93.4
50-54 years 774,350 482 62.3 366 47.3 848 109.5
55-59 years 791,036 660 83.4 602 76.1 1262 159.5
60-64 years 711,025 709 99.6 714 100.5 1423 200.1
65-70 years 586,891 670 114.2 840 143.1 1510 257.3
70-74 years 455,710 714 156.8 805 176.6 1519 333.3
75-79 years 296,135 505 170.5 772 260.8 1277 431.2
80+ years 396,781 904 227.8 1486 374.5 2390 602.3
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Racea Population ≥1 Year of Age Community Associated CDIa No.c Community Associated CDIa Incidenceb Healthcare Associated CDIa No.c Healthcare Associated CDIa Incidenceb All CDI No.c All CDI Incidenceb
White 8,073,623 5980 74.1 4907 60.8 10887 134.9
Other 3,984,708 1648 41.3 2077 52.1 3725 93.5
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Total Population ≥1 Year of Age Community Associated CDIa No.c Community Associated CDIa Incidenceb Healthcare Associated CDIa No.c Healthcare Associated CDIa Incidenceb All CDI No.c All CDI Incidenceb
All Cases 12,058,331 7628 63.3 6984 57.9 14612 121.2

a The epidemiologic classification was statistically imputed for 2% of the CDI cases selected for medical record review, and race was statistically imputed for 18% of the CDI cases selected for medical record review. The weighted frequency of cases in Colorado and Georgia was based on 33% random sampling for cases aged ≥18 years.
b Cases per 100,000 persons.
c Subcategories may not add to total due to rounding.

Table 2 – Diagnostic Assay Results of CDI Cases (N=14612)
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Diagnostic assay N %
Toxin positive 3998 27
Nucleic acid amplification test (NAAT) positive/toxin negative 4851 33
NAAT positive/toxin result unknowna 5741 39
Other methodsb 22 <1

a Includes cases diagnosed mainly by NAAT or multiplex PCR panel (i.e., toxin enzyme immunoassay or cell cytotoxicity assay was not performed) or by NAAT as part of a multistep algorithm where the toxin result was not readily known
b Includes cases diagnosed by culture or unspecified assay

Table 3 – CDI Cases by Epidemiologic Classification (N=14612)
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Epidemiologic classification N %
Hospital onset 1594 11
LTCF onset 908 6
COHCFA 2002 14
CA 4913 34
Unknowna 5195 36

a Includes 5001 non-sampled cases

Table 4 – CDI Cases by Race and Ethnicity (N=14612)
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Race/Ethnicity N %
Hispanic, any race 1061 7
Not known to be Hispanica – Whiteb 6935 47
Not known to be Hispanica – Black or African Americanc 2139 15
Not known to be Hispanica – Asiand 321 2
Not known to be Hispanica – Other or multiple racese 224 2
Non-Hispanic- Unknown race 197 1
Unknown ethnicity and race 3735 26

a Records either indicated ethnicity was non-Hispanic, or ethnicity was not known
b 716 cases with unknown ethnicity
c 153 cases with unknown ethnicity
d 50 cases with unknown ethnicity
e American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or ≥2 races reported; 79 cases with unknown ethnicity

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Table 5 – Location of CDI Cases on the Third Calendar Day Before Incident Specimen Collection (N=9611)
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Location of patient before incident specimen collection N %
Private residence 6827 71
Long-term care facility 930 10
Acute-care hospital (inpatient) 1523 16
Long-term care acute care hospital 49 <1
Homeless 70 <1
Incarcerated 10 <1
Other 4 <1
Unknown 198 2
Table 6 – Location of CDI Cases at Time of Incident Specimen Collection (N=9611)
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Location of incident specimen collection N %
Outpatient setting or emergency department 5049 53
Acute care hospital 3696 38
Long-term care facility 643 7
Long-term acute care hospital 40 <1
Other 1 <1
Unknown 182 2
Table 7 – Selected Clinical Characteristics of CDI Cases (N=7499)
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Clinical characteristic N %
Charlson comorbidity index – 0 3208 43
Charlson comorbidity index – 1 1334 18
Charlson comorbidity index – ≥2 2957 39
Underlying conditions – Cardiovascular diseasea,b 1542 21
Underlying conditions – Diabetes mellitusa 1658 22
Underlying conditions – Chronic pulmonary diseasea,c 1413 19
Underlying conditions – Gastrointestinal diseasea,d 1776 24
Underlying conditions – Gastrointestinal disease – Diverticular diseasea 784 10
Underlying conditions – Gastrointestinal disease – Inflammatory bowel diseasea 536 7
Underlying conditions – Gastrointestinal disease – Peptic ulcer diseasea 186 2
Underlying conditions – Gastrointestinal disease – Short gut syndromea 26 <1
Underlying conditions – Gastrointestinal disease – Liver diseasea 428 6
Underlying conditions – Chronic renal diseasea 1289 17
Underlying conditions – Neurologic condition, anya 1223 16
Underlying conditions – Malignancy (hematologic or solid organ)a 1244 17
Underlying conditions – Transplant (hematopoietic stem cell or solid organ)a 233 3

a Underlying conditions are not mutually exclusive
b Defined as myocardial infarction, congestive heart failure, congenital heart disease, stroke, transient ischemic attack, or peripheral vascular disease
c Defined as cystic fibrosis or any chronic respiratory condition resulting in symptomatic dyspnea
d Defined as diverticular disease, inflammatory bowel disease, peptic ulcer disease, short gut syndrome, or liver disease

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Table 8 – Selected Healthcare Exposures and Risk Factors of Incident CDI Cases in the 12 Weeks Before the Date of Incident Specimen Collection by Epidemiologic Classificationa (N=7452)
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Healthcare Exposureb CA
(N=4912),
N		 CA
(N=4912),
%		 COHCFA
(N=2002),
N		 COHCFA
(N=2002),
%		 HCFO
(N=538),
N		 HCFO
(N=538),
%
Acute care hospitalization 0 0 1963 98 286 53
Long-term care facility residence 0 0 245 12 232 43
Long-term acute care hospitalization 0 0 8 <1 15 3
Surgery 164 3 529 26 127 24
Emergency room 1030 21 789 39 154 29
Observation unit 97 2 87 4 19 4
Chronic dialysis 117 2 189 9 57 11

a Excludes 47 cases with full CRF that had unknown epidemiologic classification
b Healthcare exposure categories are not mutually exclusive

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Table 9 – Antibiotic Use in the 12 Weeks Before the Date of Incident Specimen Collection (N=7499)
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Antibiotica N %
Any antibiotic 4532 60
Aminoglycosides 87 1
Beta-lactam / beta-lactamase inhibitor combinations 1495 20
Carbapenems 209 3
Cephalosporins 2221 30
Clindamycins 560 7
Fluoroquinolones 1033 14
Glycopeptides 1327 18
Macrolides 295 4
Monobactam 24 <1
Penicillins 460 6
Trimethoprim or Trimethoprim/Sulfamethoxazole 374 5
Tetracyclines 308 4
Other antibiotic 1288 17

a Antibiotic use categories are not mutually exclusive.

Table 10 – Treatment of Incident CDI Cases (N=7499)
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Treatmenta N %
Any treatmentb 6242 83
Oral or rectal vancomycin (excluding vancomycin tapers) 4951 66
Vancomycin tapers 377 5
Metronidazole 1847 25
Fidaxomicin 217 3
Bezlotoxumab 9 <1
Stool transplant 71 <1

a Treatment categories are not mutually exclusive.
b Includes any course of CDI antibiotic therapy, bezlotoxumab, or stool transplant.

Table 11 – Outcomes of Incident CDI Cases (N=7499, except where indicated)
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Outcome N %
Toxic megacolona 25 <1
Ileusa 180 2
Pseudomembranous colitisa 29 <1
White blood cell count  >= 15,000/µla 1192 16
Recurrent infectiona 897 12
Hospitalization on the day of or within 6 days after the date of incident specimen collectiona,b 3171 42
ICU admission one day before, the day of, or within 6 days after the date of incident specimen collectiona 485 6
In-hospital deatha 148 2
Discharge location after acute-care hospitalization among patients who survivedc – Private Residence 2438 81
Discharge location after acute-care hospitalization among patients who survivedc – Long-term care facility 491 16
Discharge location after acute-care hospitalization among patients who survivedc – Long-term acute care hospital 21 <1
Discharge location after acute-care hospitalization among patients who survivedc – Other 63 2
Discharge location after acute-care hospitalization among patients who survivedc – Unknown 10 <1

a Outcomes, except for location of discharge from acute care hospitalization, are not mutually exclusive.
b Data include 353 cases considered to be hospital-onset
c N=3023

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Laboratory Characterization

This section will be updated once the data are available.

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Citation

Centers for Disease Control and Prevention. 2022. Emerging Infections Program, Healthcare Associated Infections – Community Interface Surveillance Report, Clostridioides difficileinfection (CDI), 2019 [PDF – 8 Pages]. Available at: https://www.cdc.gov/hai/eip/pdf/cdiff/2019-CDI-Report-H.pdf

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Appendix*

The percentages of community- and healthcare-associated CDI cases with C. difficile recurrence, hospitalization, and in-hospital deaths stratified by age group are shown in the following table.

Table A1.
Percentage of CDI Cases with First Recurrence, Hospitalization, and In-hospital Death by Age Group and Epidemiologic Classification

Table A1, Part 1: Community Associated
Age group and Epidemiologic Classification, Community-associated CDI casesa First Recurrenceb Hospitalizationc In-hospital Deathd
1-49 years 9 23 0.4
50-54 years 8 41 0.6
55-59 years 13 37 0.5
60-64 years 11 32 2
≥65 years 14 41 2
Table A1, Part 2: Healthcare Associated
Age group and Epidemiologic Classification, Healthcare-associated CDI casesa First Recurrenceb Hospitalizationc In-hospital Deathd
1-49 years 11 71 2
50-54 years 11 79 6
55-59 years 11 72 5
60-64 years 12 69 5
≥65 years 14 66 6

a A CDI case was classified as community-associated if the C. difficile-positive stool specimen was collected on an outpatient basis or within 3 days after hospital admission in a person with no documented overnight stay in a healthcare facility in the preceding 12 weeks. All CDI cases that do not meet the aforementioned criteria were classified as healthcare associated.
b First recurrence refers to the first recurrent CDI episode, defined as a positive stool specimen within 2 to 8 weeks after the initial positive test.
c Hospitalization includes admission at the time of or within seven days of CDI diagnosis.
d In-hospital deaths refer to deaths that occurred during hospitalization.

*The appendix Includes results of special analyses that are requested or of interest during a
particular surveillance year.

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