Healthcare facility-onset, healthcare facility-associated Clostridioides difficile infection in Veterans with spinal cord injury and disorder

Abstract

Objective: To describe the burden and risk of healthcare facility-onset, healthcare facility-associated (HO-HCFA) Clostridioides difficile infection (CDI) in Veterans with spinal cord injury and disorder (SCI/D).

Design: Retrospective, longitudinal cohort study from October 1, 2001–September 30, 2010.

Setting: Ninety-four acute care Veterans Affairs facilities.

Participants: Patients with SCI/D.

Outcomes: Incidence rate of HO-HCFA CDI.

Methods: Rates of CDI were determined, and crude unadjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated. Multivariable Poisson random-effects regression analyses were used to assess factors independently associated with the rate of CDI.

Results: 1,409 cases of HO-HCFA CDI were identified. CDI rates in 2002 were 13.9/10,000 person-days and decreased to 5.5/10,000 person-days by 2010. Multivariable regression analyses found that antibiotic (IRR = 18.79, 95% CI 14.09-25.07) and proton-pump inhibitor (PPI) or H2 blocker use (IRR = 7.71, 95% CI 5.47-10.86) were both independently associated with HO-HCFA CDI. Exposure to both medications demonstrated a synergistic risk (IRR = 37.55, 95% CI 28.39-49.67). Older age, Northeast region, and invasive respiratory procedure in the prior 30 days were also independent risk factors, while longer SCI duration and care at a SCI center were protective.

Conclusion: Although decreasing, CDI rates in patients with SCI/D remain high. Targeted antimicrobial stewardship and pharmacy interventions that reduce antibiotic and PPI/H2 blocker use could have profound benefits in decreasing HO-HCFA CDI in this high-risk population.

Keywords:

• Clostridioides difficile
• Spinal cord injury
• Proton pump inhibitor
• Antibiotics

Acknowledgement

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Disclaimer statements

Contributors None.

Funding This work was supported by the Veterans Affairs Health Services Research and Development Service under C. difficile outcomes and effectiveness of treatment strategies in SCI [IIR −10-148], Presidential Early Career Award for Scientists and Engineers [USA 12-564], and Post-Doctoral Fellowship Award [TPR 42-005].

Declaration of interest Dr. Evans has received consulting fees from Bio-K+. Dr. Smith received research funding from Mylan and AImmune. Dr. Johnson is on the advisory boards of the following companies that are developing treatments or prevention approaches for C. difficile infection: Summit Therapeutics, Seres Therapeutics, Synthetic Biologics, and Bio-K+. Dr. Gerding received fees for serving on advisory boards from Actelion Pharmaceuticals, Merck, Rebiotix, and Summit Pharmaceuticals, consulting fees from Da Volterra, Pfizer, Sanofi Pasteur, and a research grant from Seres Therapeutics, and holding patents and technology related to the treatment and prevention of C. difficile infection (US No. 6,635,260, EU No. 0952773, CAN No. 2,232,001).

Conflicts of interest See above.