Temporal Change Of Risk Factors In Hospital-Acquiredclostridioides Difficileinfection Using Time-Trend Analysis

Objective: Given recent changes in the epidemiology ofClostridioides difficileinfection (CDI) and prevention efforts, we investigated temporal changes over a period of 11 years (2006-2016) in incidence and risk factors for CDI. Design: Retrospective matched case-control study. Setting/Patients: Pediatric and adult inpatients (n = 694,849) discharged from 3 hospitals (tertiary and quaternary care, community, and pediatric) in a large, academic health center in New York City. Methods: Risk factors were identified in cases and controls matched by length of stay at a ratio of 1:4. A Cochran-Armitage or Mann-Kendall test was used to investigate trends of incidence and risk factors. Results: Of 694,849 inpatients, 6,038 (0.87%) had CDI: 44% of these cases were hospital acquired (HA-CDI) and 56% were community acquired (CA-CDI). We observed temporal downward trends in HA-CDI (-0.03% per year) and upward trends in CA-CDI (+0.04% per year). Over time, antibiotics were administered to more patients (+3% per year); the use of high-risk antibiotics declined (-1.2% per year); and antibiotic duration increased in patients with HA-CDI (+4.4% per year). Fewer proton-pump inhibitors and more histamine-2 blockers were used (-3.8% and +7.3% per year, respectively; allP(trend)<.05). Conclusions: Although the incidence of HA-CDI decreased over time, CA-CDI simultaneously increased. Continued efforts to assure judicious use of antibiotics in inpatient and community settings is clearly vital. Measuring the actual the level of exposure of an antibiotic (incidence density) should be used for ongoing surveillance and assessment.