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Regional and seasonal variation in Clostridium difficile infections among hospitalized patients in the United States, 2001-2010

  • Jacqueline R. Argamany
    Affiliations
    Pharmacotherapy Division, College of Pharmacy, University of Texas at Austin, Austin, TX

    Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX
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  • Samuel L. Aitken
    Affiliations
    Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX
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  • Grace C. Lee
    Affiliations
    Pharmacotherapy Division, College of Pharmacy, University of Texas at Austin, Austin, TX

    Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX
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  • Natalie K. Boyd
    Affiliations
    Pharmacotherapy Division, College of Pharmacy, University of Texas at Austin, Austin, TX

    Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX
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  • Kelly R. Reveles
    Correspondence
    Address correspondence to Kelly R. Reveles, PharmD, PhD, Assistant Professor, College of Pharmacy, The University of Texas at Austin and Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC-6220, San Antonio, TX 78229.
    Affiliations
    Pharmacotherapy Division, College of Pharmacy, University of Texas at Austin, Austin, TX

    Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX
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      Highlights

      • We described Clostridium difficile infections by U.S. regions and seasons.
      • We compared Clostridium difficile infection mortality by region and season.
      • Clostridium difficile infection incidence rates were highest in the Northeast and spring.
      • Clostridium difficile infection mortality rates were highest in the Midwest and winter.

      Background

      This study identified national regional and seasonal variations in Clostridium difficile infection (CDI) incidence and mortality among hospitalized patients in the United States over a 10-year period.

      Methods

      This was a retrospective cohort study of the U.S. National Hospital Discharge Survey from 2001-2010. Eligible cases had an ICD-9-CM discharge diagnosis code for CDI (008.45). Data weights were used to derive national estimates. CDI incidence and mortality were presented descriptively. Regions were as defined by the U.S. Census Bureau. Seasons included the following: winter (December-February), spring (March-May), summer (June-August), and fall (September-November).

      Results

      These data represent 2.3 million CDI discharges. Overall, CDI incidence was highest in the Northeast (8.0 CDIs/1,000 discharges) and spring (6.2 CDIs/1,000 discharges). CDI incidence was lowest in the West (4.8 CDIs/1,000 discharges) and fall (5.6 CDIs/1,000 discharges). Peak CDI incidence among children occurred in the West (1.7 CDI/1,000 discharges) and winter (1.5 CDI/1,000 discharges). Mortality among all CDI patients was highest in the Midwest (7.3%) and during the winter (7.9%).

      Conclusion

      The region and season with the highest CDI incidence rates among patients hospitalized in U.S. hospitals were the Northeast and spring, respectively. The highest CDI mortality rates were seen in the Midwest and winter. Children exhibited different regional and seasonal CDI variations compared with adults and older adults.

      Key Words

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      References

        • Pepin J.
        • Valiquette L.
        • Alary M.E.
        • Villemure P.
        • Pelletier A.
        • Forget K.
        • et al.
        Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity.
        CMAJ. 2004; 171: 466-472
      1. Lucado J, Gould C, Elixhauser A. Clostridium difficile infections (CDI) in hospital stays, 2009: statistical brief 124. Available from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf. Accessed December 23, 2014.

        • Reveles K.R.
        • Lee G.C.
        • Boyd N.K.
        • Frei C.R.
        The rise in Clostridium difficile infection incidence among hospitalized adults in the United States: 2001-2010.
        Am J Infect Control. 2014; 42: 1028-1032
        • Rupnik M.
        • Wilcox M.H.
        • Gerding D.N.
        Clostridium difficile infection: new developments in epidemiology and pathogenesis.
        Nat Rev Microbiol. 2009; 7: 526-536
        • Ghantoji S.S.
        • Sail K.
        • Lairson D.R.
        • DuPont H.L.
        • Garey K.W.
        Economic healthcare costs of Clostridium difficile infection: a systematic review.
        J Hosp Infect. 2010; 74: 309-318
        • Aitken S.L.
        • Joseph T.B.
        • Shah D.N.
        • Lasco T.M.
        • Palmer H.R.
        • DuPont H.L.
        • et al.
        Healthcare resource utilization for recurrent Clostridium difficile infection in a large university hospital in Houston, Texas.
        PLoS One. 2014; 9: e102848
        • Thomas C.
        • Stevenson M.
        • Riley T.V.
        Antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea: a systematic review.
        J Antimicrob Chemother. 2003; 51: 1339-1350
        • Donskey C.J.
        The role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens.
        Clin Infect Dis. 2004; 39: 219-226
        • Owens Jr., R.C.
        • Donskey C.J.
        • Gaynes R.P.
        • Loo V.G.
        • Muto C.A.
        Antimicrobial-associated risk factors for Clostridium difficile infection.
        Clin Infect Dis. 2008; 46: S19-S31
        • Hicks L.A.
        • Taylor Jr., T.H.
        • Hunkler R.J.
        U.S. outpatient antibiotic prescribing, 2010.
        N Engl J Med. 2013; 368: 1461-1462
        • Polgreen P.M.
        • Yang M.
        • Laxminarayan R.
        • Cavanaugh J.E.
        Respiratory fluoroquinolone use and influenza.
        Infect Control Hosp Epidemiol. 2011; 32: 706-709
        • Gilca R.
        • Fortin E.
        • Frenette C.
        • Longtin Y.
        • Gourdeau M.
        Seasonal variations in Clostridium difficile infections are associated with influenza and respiratory syncytial virus activity independently of antibiotic prescriptions: a time series analysis in Quebec, Canada.
        Antimicrob Agents Chemother. 2012; 56: 639-646
        • Suda K.J.
        • Hicks L.A.
        • Roberts R.M.
        • Hunkler R.J.
        • Taylor T.H.
        Trends and seasonal variation in outpatient antibiotic prescription rates in the United States, 2006 to 2010.
        Antimicrob Agents Chemother. 2014; 58: 2763-2766
        • Brown K.A.
        • Daneman N.
        • Arora P.
        • Moineddin R.
        • Fisman D.N.
        The co-seasonality of pneumonia and influenza with Clostridium difficile infection in the United States, 1993-2008.
        Am J Epidemiol. 2013; 178: 118-125
        • Zilberberg M.D.
        • Shorr A.F.
        • Kollef M.H.
        Growth and geographic variation in hospitalizations with resistant infections, United States, 2000-2005.
        Emerg Infect Dis. 2008; 14: 1756-1758
        • Dennison C.
        • Pokras R.
        Design and operation of the National Hospital Discharge Survey: 1988 redesign.
        Vital Health Stat. 2000; : 1-42
      2. Elixhauser A, Jhung M. Clostridium difficile-associated disease in U.S. hospitals, 1993-2005: statistical brief 50. Available from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf. Accessed September 13, 2014.

        • Archibald L.K.
        • Banerjee S.N.
        • Jarvis W.R.
        Secular trends in hospital-acquired Clostridium difficile disease in the United States, 1987–2001.
        J Infect Dis. 2004; 189: 1585-1589
        • McDonald L.C.
        • Owings M.
        • Jernigan D.B.
        Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003.
        Emerg Infect Dis. 2006; 12: 409-415
        • Bauer M.P.
        • Notermans D.W.
        • van Benthem B.H.
        • Brazier J.S.
        • Wilcox M.H.
        • Rupnik M.
        • et al.
        Clostridium difficile infection in Europe: a hospital-based survey.
        Lancet. 2011; 377: 63-73
        • Bignardi G.E.
        Risk factors for Clostridium difficile infection.
        J Hosp Infect. 1998; 40: 1-15
      3. Centers for Disease Control and Prevention. Number, rate, and average length of stay for discharges from short-stay hospitals, by age, region, and sex: United States, 2010. Available from: http://www.cdc.gov/nchs/data/nhds/1general/2010gen1_agesexalos.pdf. Accessed September 13, 2014.

        • Gerding D.N.
        • Olson M.M.
        • Peterson L.R.
        • Teasley D.G.
        • Gebhard R.L.
        • Schwartz M.L.
        • et al.
        Clostridium difficile-associated diarrhea and colitis in adults. A prospective case-controlled epidemiologic study.
        Arch Intern Med. 1986; 146: 95-100
        • See I.
        • Mu Y.
        • Cohen J.
        • Beldavs Z.G.
        • Winston L.G.
        • Dumyati G.
        • et al.
        NAP1 strain type predicts outcomes from Clostridium difficile infection.
        Clin Infect Dis. 2014; 58: 1394-1400
        • Tickler I.A.
        • Goering R.V.
        • Whitmore J.D.
        • Lynn A.N.
        • Persing D.H.
        • Tenover F.C.
        • et al.
        Strain types and antimicrobial resistance patterns of Clostridium difficile isolates from the United States, 2011 to 2013.
        Antimicrob Agents Chemother. 2014; 58: 4214-4218
        • Cohen S.H.
        • Gerding D.N.
        • Johnson S.
        • Kelly C.P.
        • Loo V.G.
        • McDonald L.C.
        • et al.
        Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA).
        Infect Control Hosp Epidemiol. 2010; 31: 431-455
        • McDonald L.C.
        • Killgore G.E.
        • Thompson A.
        • Owens Jr., R.C.
        • Kazakova S.V.
        • Sambol S.P.
        • et al.
        An epidemic, toxin gene-variant strain of Clostridium difficile.
        N Engl J Med. 2005; 353: 2433-2441
        • Aldeyab M.A.
        • Harbarth S.
        • Vernaz N.
        • Kearney M.P.
        • Scott M.G.
        • Funston C.
        • et al.
        Quasiexperimental study of the effects of antibiotic use, gastric acid-suppressive agents, and infection control practices on the incidence of Clostridium difficile-associated diarrhea in hospitalized patients.
        Antimicrob Agents Chemother. 2009; 53: 2082-2088
        • Polgreen P.M.
        • Yang M.
        • Bohnett L.C.
        • Cavanaugh J.E.
        A time-series analysis of Clostridium difficile and its seasonal association with influenza.
        Infect Control Hosp Epidemiol. 2010; 31: 382-387
        • Fridkin S.
        • Baggs J.
        • Fagan R.
        • Magill S.
        • Pollack L.A.
        • Malpiedi P.
        • et al.
        Vital signs: improving antibiotic use among hospitalized patients.
        MMWR Morb Mortal Wkly Rep. 2014; 63: 194-200
        • Reichert T.A.
        • Simonsen L.
        • Sharma A.
        • Pardo S.A.
        • Fedson D.S.
        • Miller M.A.
        Influenza and the winter increase in mortality in the United States, 1959-1999.
        Am J Epidemiol. 2004; 160: 492-502
        • Kalkstein A.J.
        Regional similarities in seasonal mortality across the United States: an examination of 28 metropolitan statistical areas.
        PLoS One. 2013; 8: e63971
      4. United States Census Bureau. Age and sex composition: 2010. Available from: http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf. Accessed September 13, 2014.

        • Saynajakangas P.
        • Keistinen T.
        • Tuuponen T.
        Seasonal fluctuations in hospitalisation for pneumonia in Finland.
        Int J Circumpolar Health. 2001; 60: 34-40
        • Johnston N.W.
        The similarities and differences of epidemic cycles of chronic obstructive pulmonary disease and asthma exacerbations.
        Proc Am Thorac Soc. 2007; 4: 591-596
        • Dubberke E.R.
        • Reske K.A.
        • McDonald L.C.
        • Fraser V.J.
        ICD-9 codes and surveillance for Clostridium difficile-associated disease.
        Emerg Infect Dis. 2006; 12: 1576-1579
        • Surawicz C.M.
        • Brandt L.J.
        • Binion D.G.
        • Ananthakrishnan A.N.
        • Curry S.R.
        • Gilligan P.H.
        • et al.
        Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections.
        Am J Gastroenterol. 2013; 108 (quiz 99): 478-498
        • McFarland L.V.
        • Surawicz C.M.
        • Rubin M.
        • Fekety R.
        • Elmer G.W.
        • Greenberg R.N.
        Recurrent Clostridium difficile disease: epidemiology and clinical characteristics.
        Infect Control Hosp Epidemiol. 1999; 20: 43-50
        • Garey K.W.
        • Sethi S.
        • Yadav Y.
        • DuPont H.L.
        Meta-analysis to assess risk factors for recurrent Clostridium difficile infection.
        J Hosp Infect. 2008; 70: 298-304