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Community-associated infections (CA-CDI) have increased worldwide. Patients with CDI-related symptoms occurring < 48 hours after hospitalisation and no inpatient stay 12 weeks prior are classified as CA-CDI, regardless of hospital day attendances 3 months before CDI onset. Healthcare-associated (HA) CDIs include those with symptom onset ≥ 48 hours post hospitalisation.


To consider an incubation period more reflective of CDI, and changing healthcare utilisation, we measured how varying surveillance specifications to categorise patients according to their CDI origin resulted in changes in patients’ distribution among CDI origin categories.


New CDI cases between 2012–2021 from our hospital were reviewed. For patients with CA-CDI, hospital day attendances in the 3 months prior were recorded. CA-CDI patients with hospital day attendances and recently discharged CDI patients (RD-CDI; CDI onset 4–12 weeks after discharge) were combined into a new ‘healthcare-exposure’ category (HE-CDI). Time from hospitalisation to disease onset was varied and the midpoint between optimal and balanced cut-offs was used instead of 48 hours to categorise HA-CDI.


Of 1,047 patients, 801 (76%) were HA-CDI, 205 (20%) CA-CDI and 41 (4%) were RD-CDI. Of the CA-CDI cohort, 45 (22%) met recent HE-CDI criteria and, when reassigned, reduced CA-CDI to 15%. Sensitivity analysis indicated a day 4 cut-off for assigning HA-CDI. Applying this led to 46 HA-CDI reassigned as CA-CDI. Applying both HE and day 4 criteria led to 72% HA-CDI, 20% CA-CDI, and 8% HE-CDI (previously RD-CDI).


CDI surveillance specifications reflecting healthcare exposure and an incubation period more characteristic of may improve targeted CDI prevention interventions.


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  1. Kola A, Wiuff C, Akerlund T, van Benthem BH, Coignard B, Lyytikäinen O, et al. , members of ECDIS-Net. Survey of Clostridium difficile infection surveillance systems in Europe, 2011. Euro Surveill. 2016;21(29):30291.  https://doi.org/10.2807/1560-7917.ES.2016.21.29.30291  PMID: 27469420 
  2. van Dorp SM, Kinross P, Gastmeier P, Behnke M, Kola A, Delmée M, et al. , European Clostridium difficile Infection Surveillance Network (ECDIS-Net) on behalf of all participants. Standardised surveillance of Clostridium difficile infection in European acute care hospitals: a pilot study, 2013. Euro Surveill. 2016;21(29):30293.  https://doi.org/10.2807/1560-7917.ES.2016.21.29.30293  PMID: 27472820 
  3. Health Protection Surveillance Centre (HPSC). Case Definitions for C. difficile Enhanced Surveillance. Dublin: HPSC; 2014. Available from: https://www.hpsc.ie/a-z/microbiologyantimicrobialresistance/clostridioidesdifficile/enhancedsurveillance/File,14699,en.pdf
  4. European Centre for Disease and Control (ECDC). European surveillance of Clostridioides (Clostridium) difficile infections. Surveillance protocol version 2.4. Stockholm: ECDC; 2019. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/clostridium-difficile-infections-EU-surveillance-protocol-vers2.4.pdf
  5. Haley RW, Quade D, Freeman HE, Bennett JV. The SENIC Project. Study on the efficacy of nosocomial infection control (SENIC Project). Summary of study design. Am J Epidemiol. 1980;111(5):472-85.  https://doi.org/10.1093/oxfordjournals.aje.a112928  PMID: 6246798 
  6. Krutova M, Kinross P, Barbut F, Hajdu A, Wilcox MH, Kuijper EJ, et al. , survey contributors. How to: Surveillance of Clostridium difficile infections. Clin Microbiol Infect. 2018;24(5):469-75.  https://doi.org/10.1016/j.cmi.2017.12.008  PMID: 29274463 
  7. Fu Y, Luo Y, Grinspan AM. Epidemiology of community-acquired and recurrent Clostridioides difficile infection. Therap Adv Gastroenterol. 2021;14:17562848211016248.  https://doi.org/10.1177/17562848211016248  PMID: 34093740 
  8. Viprey VF, Davis GL, Benson AD, Ewin D, Spittal W, Vernon JJ, et al. , COMBACTE-CDI National Coordinators, COMBACTE-CDI consortium, Members of the COMBACTE-CDI National coordinators. A point-prevalence study on community and inpatient Clostridioides difficile infections (CDI): results from Combatting Bacterial Resistance in Europe CDI (COMBACTE-CDI), July to November 2018. Euro Surveill. 2022;27(26):2100704.  https://doi.org/10.2807/1560-7917.ES.2022.27.26.2100704  PMID: 35775426 
  9. Thornton CS, Rubin JE, Greninger AL, Peirano G, Chiu CY, Pillai DR. Epidemiological and genomic characterization of community-acquired Clostridium difficile infections. BMC Infect Dis. 2018;18(1):443.  https://doi.org/10.1186/s12879-018-3337-9  PMID: 30170546 
  10. Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infect Drug Resist. 2014;7:63-72. PMID: 24669194 
  11. Skally M, Bennett K, Burns K, Brennan R, Finn C, O’Connell K, et al. A decade of Clostridioides difficile infection: a constant challenge to maintain the status quo. J Hosp Infect. 2023;135:59-66.  https://doi.org/10.1016/j.jhin.2023.02.008  PMID: 36863458 
  12. Clancy C, Shine C, Hennessy M. Spending Review 2022 Hospital Performance: An Analysis of HSE Key Performance Indicators. Irish Government Economic and Evaluation Service Research Services & Policy Unit, Department of Health. 2023. Available from: https://assets.gov.ie/267888/568d98d8-32a3-48c5-9614-d081d8bbc5bf.pdf
  13. Samore MH, Venkataraman L, DeGirolami PC, Arbeit RD, Karchmer AW. Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med. 1996;100(1):32-40.  https://doi.org/10.1016/S0002-9343(96)90008-X  PMID: 8579084 
  14. McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):e1-48.  https://doi.org/10.1093/cid/cix1085  PMID: 29462280 
  15. Fitzpatrick F, Riordan MO. Performance management of Clostridium difficile infection in hospitals - The carrot or stick approach? Anaerobe. 2016;37:8-12.  https://doi.org/10.1016/j.anaerobe.2015.10.001  PMID: 26456187 
  16. Health Protection Surveillance Centre (HPSC). Clostridioides difficile infection in Ireland 2020. Dublin: HPSC; 2022. Available from: https://www.hpsc.ie/a-z/microbiologyantimicrobialresistance/clostridioidesdifficile/cdifficiledataandreports/annualreports/AER_CDI_2019_2020_Reviewed.pdf
  17. Almond J, Leal J, Bush K, Rogers E, Henderson EA, Ellison J. Hospital-acquired Clostridioides difficile infections in Alberta: The validity of laboratory-identified event surveillance versus clinical infection surveillance. Am J Infect Control. 2020;48(6):633-7.  https://doi.org/10.1016/j.ajic.2019.09.029  PMID: 31733811 
  18. Thacker SB, Parrish RG, Trowbridge FL. A method for evaluating systems of epidemiological surveillance. World Health Stat Q. 1988;41(1):11-8. PMID: 3269210 
  19. Department of Health publishes Health in Ireland Key Trends 2022. Department of Health. Ireland; 2022. Available from: https://www.gov.ie/en/press-release/ddb4d-department-of-health-publishes-health-in-ireland-key-trends-2022/
  20. Gerhardt W, Arora A. Hospital revenue trends. Outpatient, home, virtual, and other care settings are becoming more common. Deloitte. Available from: https://www2.deloitte.com/us/en/insights/industry/health-care/outpatient-virtual-health-care-trends.html
  21. Kuntz JL, Polgreen PM. The importance of considering different healthcare settings when estimating the burden of Clostridium difficile. Clin Infect Dis. 2015;60(6):831-6.  https://doi.org/10.1093/cid/ciu955  PMID: 25477426 
  22. Jury LA, Sitzlar B, Kundrapu S, Cadnum JL, Summers KM, Muganda CP, et al. Outpatient healthcare settings and transmission of Clostridium difficile. PLoS One. 2013;8(7):e70175.  https://doi.org/10.1371/journal.pone.0070175  PMID: 23894609 
  23. Cohen B, Levine M, Kamboj M. Clostridium difficile infection following outpatient cancer surgery. Infect Control Hosp Epidemiol. 2019;40(12):1440-1.  https://doi.org/10.1017/ice.2019.277  PMID: 31607280 
  24. Health Protection Surveillance Centre (HPSC). Enhanced Surveillance of Clostridioides (Clostridium) difficile Infection in Ireland: Q1 2023 National Report. Health Protection Surveillance Centre; Q3. Dublin: HPSC; 2022. Available from: https://www.hpsc.ie/a-z/microbiologyantimicrobialresistance/clostridioidesdifficile/cdifficiledataandreports/CDINationalReport_Q12023_v1.0_Final.pdf
  25. Saeed K, Petridou C, Gray H, Dryden M, Davis-Blues K, Lucero S, et al. Clostridium difficile multidisciplinary team root cause analysis: impact on clinical care and circumvention of financial penalties posed by clinical commissioning groups, but at what cost? J Infect Prev. 2018;19(2):54-61.  https://doi.org/10.1177/1757177417726155  PMID: 29552095 
  26. McLure A, Clements ACA, Kirk M, Glass K. Clostridium difficile classification overestimates hospital-acquired infections. J Hosp Infect. 2018;99(4):453-60.  https://doi.org/10.1016/j.jhin.2017.12.014  PMID: 29258917 
  27. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453-7.  https://doi.org/10.1016/S0140-6736(07)61602-X  PMID: 18064739 

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