Clostridium difficile: The More We Learn, the Less We Know

• Published in: Infection control and hospital epidemiology Vol. 37; no. 1; pp. 16 - 18
• Main Author: Roth, Virginia R.
• Format: Journal Article
• Language: English
• Published: New York, USA Cambridge University Press 01-01-2016
• Subjects: Anti-Bacterial Agents - therapeutic use; Antibiotics; Asymptomatic; Clostridium difficile; Clostridium Infections - drug therapy; Commentary; Disease control; Enterocolitis, Pseudomembranous - drug therapy; Environmental risk; Epidemics; Epidemiology; Flora; Health care; Hospitals; Humans; Infections; Ingestion; Laboratory methods; Mortality; Nosocomial infection; Nursing; Pathogens; Patients; Performance evaluation; Population studies
• ISSN: 0899-823X; 1559-6834
• DOI: 10.1017/ice.2015.257

Acquisition is traditionally thought to involve the ingestion of spores from the contaminated healthcare environment by patients whose normal bowel flora is altered by antibiotics.1 While the majority of these patients remain asymptomatic, some develop diarrhea, further contaminating the environment and serving as a source of ongoing transmission.1,2 Clabots et al3 demonstrated that the rate of C. difficile acquisition is linearly correlated with length of hospital stay, lending further support to the role of the hospital environment as an important reservoir of C. difficile. [...]prevention efforts have relied largely on measures aimed toward reducing the risk of environmental spread within the healthcare setting such as contact precautions and environmental disinfection, as well as antimicrobial stewardship.4 For many years, C. difficile was generally regarded as an inconvenient but readily treatable cause of antibiotic-associated diarrhea. Conversely, this study found microbiologic evidence of nosocomial acquisition in only 21% of cases, and only half of those had an epidemiologic link to an earlier patient with identical strain type. [...]healthcare acquisition could be established in only a very small proportion of cases. A large population-based study in the United States estimated that only 24% of all C. difficile infections are acquired during hospital admission, while the rest may be linked to outpatient healthcare settings or community acquisition.20 It has been postulated that food, animals, and healthy infants could serve as community reservoirs for this pathogen,21,22 though epidemiologic studies have failed to confirm any of these as important sources of infection in humans.23 While we lack full knowledge of the reservoirs of C. difficile, there is growing evidence that colonization in the community can lead to the subsequent development of C. difficile infection in the setting of antibiotic use, proton pump inhibitor use, or hospital admission.18,24–26 The current study by Kamboj et al18 along with the earlier study by Eyre et al19 demonstrate that current surveillance definitions and laboratory methods are too crude to accurately attribute C. difficile acquisition to a particular healthcare setting or inpatient unit.