Original Investigation
June 2016

Effect of Detecting and Isolating Clostridium difficile Carriers at Hospital Admission on the Incidence of C difficile InfectionsA Quasi-Experimental Controlled Study

Author Affiliations
  • 1Infection Prevention and Control Unit, Jewish General Hospital Sir Mortimer B. Davis, Montreal, Québec, Canada
  • 2Faculty of Medicine, McGill University, Montreal, Québec, Canada
  • 3Infection Control Unit, Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec City, Canada
  • 4Institut National de Santé Publique du Québec, Québec City, Canada
  • 5Centre Hospitalier Universitaire de Québec, Québec City, Canada
  • 6Faculty of Medicine, Université Laval, Québec City, Québec, Canada
  • 7Centre de Recherche en Infectiologie de l’Université Laval, Québec City, Québec, Canada
  • 8Laboratoire de Santé Publique du Québec, Institut National de Santé Publique du Québec, Sainte-Anne-de-Bellevue, Canada
  • 9Department of Infectious Diseases, Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec City, Canada
  • 10Infectious Diseases Unit, Chaim Sheba Medical Center, Tel HaShomer, Israel
  • 11Department of Pharmacy, Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec City, Canada
  • 12Division of Infectious Diseases, McGill University Health Centre, Montreal, Québec, Canada

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Intern Med. 2016;176(6):796-804. doi:10.1001/jamainternmed.2016.0177

Importance  Clostridium difficile infection (CDI) is a major cause of health care–associated infection worldwide, and new preventive strategies are urgently needed. Current control measures do not target asymptomatic carriers, despite evidence that they can contaminate the hospital environment and health care workers’ hands and potentially transmit C difficile to other patients.

Objective  To investigate the effect of detecting and isolating C difficile asymptomatic carriers at hospital admission on the incidence of health care–associated CDI (HA-CDI).

Design, Setting, and Participants  We performed a controlled quasi-experimental study between November 19, 2013, and March 7, 2015, in a Canadian acute care facility. Admission screening was conducted by detecting the tcdB gene by polymerase chain reaction on a rectal swab. Carriers were placed under contact isolation precautions during their hospitalization.

Main Outcomes and Measures  Changes in HA-CDI incidence level and trend during the intervention period (17 periods of 4 weeks each) were compared with the preintervention control period (120 periods of 4 weeks each) by segmented regression analysis and autoregressive integrated moving average (ARIMA) modeling. Concomitant changes in the aggregated HA-CDI incidence at other institutions in Québec City, Québec (n = 6) and the province of Québec (n = 94) were also examined.

Results  Overall, 7599 of 8218 (92.5%) eligible patients were screened, among whom 368 (4.8%) were identified as C difficile carriers. During the intervention, 38 patients (3.0 per 10 000 patient-days) developed an HA-CDI compared with 416 patients (6.9 per 10 000 patient-days) during the preintervention control period (P < .001). There was no immediate change in the level of HA-CDIs on implementation (P = .92), but there was a significant decrease in trend over time of 7% per 4-week period (rate ratio, 0.93; 95% CI, 0.87-0.99 per period; P = .02). ARIMA modeling also detected a significant effect of the intervention, represented by a gradual progressive decrease in the HA-CDI time series by an overall magnitude of 7.2 HA-CDIs per 10 000 patient-days. We estimated that the intervention had prevented 63 of the 101 (62.4%) expected cases. By contrast, no significant decrease in HA-CDI rates occurred in the control groups.

Conclusions and Relevance  Detecting and isolating C difficile carriers was associated with a significant decrease in the incidence of HA-CDI. If confirmed in subsequent studies, this strategy could help prevent HA-CDI.