Clostridium difficile Infection (CDI) Tracking
The Clostridium difficile infection (CDI) surveillance program is an active population- and laboratory-based surveillance system conducted through CDC’s Emerging Infections Program (EIP) Healthcare-Associated Infections Community Interface (HAIC) activity. Data from the EIP CDI program can be used to measure the burden of CDI in the population, characterize C. difficile strains associated with disease, and to monitor trends in disease over time. The CDI surveillance program also provides an infrastructure for further public health research, including special studies aimed at identifying risk factors for C. difficile disease, population targets for vaccine, and monitoring effectiveness of prevention strategies. The EIP CDI surveillance was launched in 2009 in 7 EIP sites. It currently operates in select counties in 10 EIP sites across the United States and has approximately 11.7 million people under surveillance.
- Monitor the population-based incidence and disease burden of community– and healthcare–associated CDI
- Characterize C. difficile strains causing disease in the population under surveillance with a focus on strains from community–associated cases, and describe changes in strain prevalence over time
- Describe changes in the epidemiology of CDI with a focus on cases occurring outside of acute care settings
The table below illustrates the estimated population under surveillance for each EIP site as of December 2013.
|Areas Under Surveillance||2011||2012||2013||2014|
|San Francisco County, CA||812,826||825,863||837,442||852,469|
|Adams, Arapahoe, Denver, Douglas and Jefferson Counties, CO||2,488,410||2,532,982||2,583,519||2,636,542|
|New Haven County, CT||861,113||862,813||862,287||861,277|
|Clayton, Cobb, DeKalb, Douglas, Fulton, Gwinnet, Newton and Rockdale Counties, GA||3,753,452||3,821,534||3,864,091||3,925,130|
|Caroline, Cecil, Dorchester, Frederick, Kent, Somerset, Talbot, Queen Anne’s, Washington, Wicomico and Worcester Counties, MD||835,893||841,089||843,444||846,087|
|Benton, Morrison, Olmsted (surveillance began July 2012), Stearns and Todd Counties, MN||248,079||395,098||397,786||399,779|
|Bernalillo County, NM||670,968||673,460||674,221||675,551|
|Monroe County, NY||745,625||747,813||749,606||749,857|
|Klamath County, OR*||66,299||228,189||231,864||65,455|
|Davidson County, TN||635,475||648,295||658,602||668,347|
*Deschutes County, OR participated in CDI surveillance during 2012-2013.
C. difficile infection Incident Case
A case of CDI is defined as a positive C. difficile toxin assay or a positive C. difficile molecular assay (e.g. PCR) of a stool specimen from a resident of the surveillance catchment area who is 1 year of age or older. Cases with a C. difficile-positive stool specimen greater than 8 weeks after the last positive specimen are considered a new case with an incident stool specimen. Therefore, for surveillance purposes, an individual may be classified and captured as a new incident case if eight consecutive weeks have elapsed since their last C. difficile-positive test.
CDI cases with a positive C. difficile stool specimen between 2 to 8 weeks of the last positive specimen are considered recurrent episodes.
CDI cases with a positive C. difficile stool specimen less than 2 weeks since the last positive specimen are considered duplicate episodes.
CDI cases are identified based on reports of positive C. difficile toxin assay or C. difficile nucleic acid amplification assay from all clinical, reference, and commercial laboratories that serve the population in the surveillance catchment areas. Each laboratory regularly provides line listings of positive C. difficile test results to the local EIP site. The line listings include the patient name and local laboratory identifier, date of specimen collection, as well as any additional available information (e.g. address, date of birth, age, sex, location of stool collection). Information on additional positive specimens from the same patient is recorded for the purpose of ascertaining and tracking recurrent or duplicate episodes, as well as new cases (i.e., greater than eight weeks after the last positive C. difficile specimen).
Data Collection and Epidemiologic Classification
Data collection is performed by trained surveillance epidemiologists at each EIP site. For each incident CDI case identified in 8 of the 10 EIP sites, a brief medical-record review is performed to gather basic demographic characteristics, location of stool collection, and healthcare exposures. In the 2 remaining EIP sites with the largest surveillance populations (Colorado and Georgia), a brief medical-record review is performed on a random sample of cases. Medical record reviews are not completed on recurrent or duplicate episodes or patients determined to reside outside the catchment area. CDI cases are classified into three epidemiologic categories: healthcare facility-onset (HCFO), if the positive stool specimen was collected greater than 3 calendar days after hospital admission or in a resident of a long-term care facility; community-onset healthcare facility-associated (CO-HCFA), if the positive stool specimen was collected in an outpatient setting or within 3 days after hospital admission in a person with documented overnight stay in a healthcare facility (i.e., history of hospitalization or long-term care facility residency in the 12 weeks before stool specimen collection); and community–associated (CA), if positive stool specimen was collected in an outpatient setting or within 3 calendar days in a person with no documented overnight stay in a healthcare facility during the 12 weeks before the specimen was collected. All CA and CO-HFCA cases and a random sample (10%) of HCFO cases subsequently undergo a comprehensive medical-record review for clinical information and relevant risk factors.
A convenience sample of stool specimens from incident CDI cases with complete clinical and epidemiologic information are sent to reference laboratories for C. difficile isolation. Isolates recovered are then sent to CDC for molecular characterization. Each isolate undergoes polymerase chain reaction (PCR)-screening for the tcdA, tcdB, cdtA and cdtB toxin genes, and deletions in tcdC are assessed by fragment analysis. Strain typing is performed using capillary-based PCR-ribotyping and results are analyzed against a library of standard profiles using BioNumerics.
Rates of CDI are calculated using population estimates for the specified year. Cases with missing data (e.g., race) are multiply imputed using sequential regression imputation methods. A domain (subpopulation) analysis is performed to estimate the number of cases according to epidemiologic class and race in the two EIP sites where sampling was performed (Colorado and Georgia).
Response to Inaccuracies in Clostridium difficile Infection (CDI) Data
- AS Chitnis, SM Holzbauer, RM Belflower, LG Winston, WM Bamberg, C Lyons, MM Farley, GK Dumyati, LE Wilson, ZG Beldavs, JR Dunn, LH Gould, DR MacCannell, DN Gerding, LC McDonald, FC Lessa. Epidemiology of community-associated Clostridium difficile infection, 2009–2011. JAMA Intern Med 2013;173:1359-67.
- Centers for Disease Control and Prevention (CDC). Vital Signs: Preventing Clostridium difficile infections. MMWR Morb Mortal Wkly Rep. 2012;61(9):157-62.
- Pawar D, Tsay R, Nelson DS, Elumalai MK, Lessa FC, Clifford McDonald L, Dumyati G. Burden of Clostridium difficile infection in long-term care facilities in Monroe County, New York. Infect Control Hosp Epidemiol. 2012;33(11):1107-12.
- Gould CV, Edwards JR, Cohen J, Bamberg WM, Clark LA, Farley MM, Johnston H, Nadle J, Winston L, Gerding DN, McDonald LC, Lessa FC. Effect of nucleic acid amplification testing on population-based incidence rates of Clostridium difficile infection. Clin Infect Dis 2013;57(9):1304-7.
- Cohen J, Limbago L, Dumyati G, Holzbauer S, Johnston H, Perlmutter R, Dunn J, Nadle J, Lyons C, Beldavs ZG, Clark LA, Lessa FC. Impact of changes in Clostridium difficile testing practices on stool rejection policies and C. difficile positivity rates across multiple laboratories in the United States. J Clin Microbiol. 2014;52(2):632-4.
- Wendt JM, Cohen JA, Mu Y, Dumyati GK, Dunn JR, Holzbauer SM, Winston LG, Johnston H, Meek JI, Farley MM, Wilson LE, Phipps EC, Beldavs ZG, Gerding DN, McDonald LC, Gould CV, Lessa FC. Clostridium difficile infection among children across diverse US geographic locations. Pediatrics. 2014;133(4):651-8.
- See I, Mu Y, Cohen J, Beldavs ZG, Winston LG, Dumyati G, Holzbauer S, Dunn JR, Farley MM, Lyons C, Johnston H, Phipps E, Perlmutter R, Anderson L, Gerding DN, Lessa FC. NAP1 strain type is a predictor of outcomes from Clostridium difficile infection. Clin Infect Dis 2014;58(10):1394-400.
- Lessa FC, Mu Y, Winston L, Dumyati G, Farley MM, Beldavs Z, Kast K, Holzbauer SM, Meek JI, Cohen J, McDonald LC, Fridkin SK. Determinants of Clostridium difficile infection incidence across diverse U.S. geographic locations. Open Forum Infect Dis 2014;1(2):ofu048. doi: 10.1093/ofid/ofu048.
- Rhee SM, Tsay R, Nelson DS, Wijngaarden E, Dumyati G. Clostridium difficile in the Pediatric Population of Monroe County, NY. J Ped Infect Dis 2014;3:183-8.
- Lessa FC, Winston LG, McDonald LC; Emerging Infections Program C. difficile Surveillance Team. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372(24):2369-70.
- 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 LG, Less FC. Association between outpatient antibiotic prescribing practices and community-associated Clostridium difficile infection. Open Forum Infect Dis. 2015. doi: 10.1093/ofid/ofv113. First published online: August 11, 2015.
- Baggs J, Yousey-Hindes K, Ashley ED, Meek J, Dumyati G, Cohen J, Wise ME, McDonald LC, Lessa FC. Identification of population at risk for future Clostridium difficile infection following hospital discharge to be targeted for vaccine trials. Vaccine. 2015 Nov 17;33(46):6241-9.
- 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. Burden of Nursing Home-Onset Clostridium difficile Infection in the United States: Estimates of Incidence and Patient Outcomes. Open Forum Infect Dis. 2016 Jan 18;3(1):ofv196.
- Page last reviewed: September 11, 2015
- Page last updated: January 13, 2017
- Content source: