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Invited Commentary
Infectious Diseases
January 8, 2020

Incidence and Outcome of Clostridium difficile Infection—Beware of Strain Type and Diagnostic Tests

Author Affiliations
  • 1Research and Development, Edward Hines Jr VA Hospital, Hines, Illinois
JAMA Netw Open. 2020;3(1):e1918599. doi:10.1001/jamanetworkopen.2019.18599

Clostridium difficile (also known as Clostridioides difficile) infection (CDI) is one of the most common health care–associated (HCA) infections and is a significant cause of morbidity and mortality, especially among older adult hospitalized patients. Although the incidence of HCA CDI and its attributable hospital length of stay (LOS) have appeared to be increasing nationally in the United States, they are highly dependent on the frequency of epidemic or outbreak strains, which influence both the rate and severity of CDI and changes over time. In addition, variable definitions of CDI influenced by a changing diagnostic paradigm can lead to both overdiagnosis and underdiagnosis. Other factors that contribute to the uncertainty are the inclusion of patients younger than 2 years (because they have high rates of asymptomatic colonization), the inclusion of patients only with specific underlying illnesses (eg, cancer or stem cell transplant) or at specific hospital locations (eg, intensive care unit residence), failure to exclude recurrent and multiply recurrent CDI cases from primary CDI totals, and a multiplicity of denominators used to calculate incidence in person-years.

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