# Presentation: 778953

## Laboratory Positive Clostridium difficile:  BioSense 2007-2008

**Stephen R. Benoit, MD, MPH**
**Nikolay Lipskiy, PhD, MBA**
**Roseanne English, BS**
**Jerome Tokars, MD, MPH**
**National Center for Public Health Informatics**
**Centers for Disease Control and Prevention**

*The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention*

## Clostridium difficile Infection (CDI)

- Anaerobic, spore-forming bacillus
- Wide spectrum of disease
- 	Simple diarrhea
- 			Pseudomembranous colitis
- 			Toxic megacolon
- 				  Sepsis and death
- Transmission through contaminated environment & hands of healthcare personnel
- Risk factor:  recent antimicrobial exposure

- Pseudo-membranous colitis

- Healthy colon

*C. difficile*

## Changing Epidemiology of Clostridium difficile

**Notes:**
Clostridium difficile, ... anaerobic spore-forming bacillus, 
is the most common cause of Clostridium difficile-Associated Diarrhea 
or CDAD.  

Complications of CDAD may be severe and include pseudomembranous colitis, 
toxic megacolon, sepsis, and death. 

Transmission of C. difficile occurs through oro-fecal route via contaminated 
environment and hands of healthcare workers.

Antimicrobial exposure is the major risk factor for disease as it promotes 
acquisition and growth of C. difficile through suppression of normal bacterial
flora of the colon.

Many studies have shown that use of antimicrobial agents such as clindamycin, 
penicillins, and cephalosporins for the treatment of respiratory infections and 
other unrelated conditions have been associated with development CDAD.

## Figure 1. Trends in hospital stays associated with  Clostridium difficile-associated disease, 1993-2005

**Numbers of discharges, in thousands**

**Figure 1. Trends in hospital stays associated with **** Clostridium difficile-associated disease, 1993-2005**

- From Elixhauser A, *Clostridium difficile*-associated disease in U.S. Hospitals, 1993–2005*. *HCUP Statistical Brief #50. April 2008.

## Clostridium difficile–related Mortality by Listing on Death Certificates, United States—1999-2004

*Clostridium difficile–*related Mortality by Listing on Death Certificates, United States—1999-2004

- Adapted from Redelings MD, *et al*. Emerg Infect Dis. 2007

- Deaths per Million Population

## C.difficile in Previously Low-Risk Populations

- 10 pregnant women
- 23 generally healthy persons in the community
- Cases *without* precedent antimicrobial use

- Centers for Disease Control and Prevention. *MMWR Morbid Mortal Wkly Rep*. 2005

## Hospitals should conduct surveillance for CDI
Track positive laboratory results (e.g., toxin assays)
Consider measures to track outcomes
Determine Healthcare vs. Community-associated disease if possible

- Track positive laboratory results (e.g., toxin assays)
- Consider measures to track outcomes
- Determine Healthcare vs. Community-associated disease if possible

- Recommendations from Ad Hoc *C. difficile* Surveillance Working Group

## BioSense

- Surveillance system designed for:
- Disease detection
- Monitoring
- Real-time health situational awareness
- Data sources:
- Non-federal hospitals:  569
- Veteran’s Administration facilities:  833
- Department of Defense facilities:  355
- Data types:
- Chief complaints, working and final diagnoses
- Subset of hospitals:  laboratory*, radiology, pharmacy data

- * Focus of this study

**Notes:**
Clostridium difficile, ... anaerobic spore-forming bacillus, 
is the most common cause of Clostridium difficile-Associated Diarrhea 
or CDAD.  

Complications of CDAD may be severe and include pseudomembranous colitis, 
toxic megacolon, sepsis, and death. 

Transmission of C. difficile occurs through oro-fecal route via contaminated 
environment and hands of healthcare workers.

Antimicrobial exposure is the major risk factor for disease as it promotes 
acquisition and growth of C. difficile through suppression of normal bacterial
flora of the colon.

Many studies have shown that use of antimicrobial agents such as clindamycin, 
penicillins, and cephalosporins for the treatment of respiratory infections and 
other unrelated conditions have been associated with development CDAD.

## 32 of 50 hospitals (12 states) had C. difficile positive laboratory results between Jan 1, 2007 through Jun 30, 2008

**32 of 50 hospitals (12 states) had C. difficile positive laboratory results between Jan 1, 2007 through Jun 30, 2008**
**Median (range) hospital bed size = 318 (44, 1039)**

## Objectives

- Determine the feasibility of using BioSense laboratory data for surveillance on a disease of public health importance
- Apply surveillance definitions and calculate overall and facility rates of disease based on definitions created by the *C. difficile* Surveillance Working Group

**Notes:**
Clostridium difficile, ... anaerobic spore-forming bacillus, 
is the most common cause of Clostridium difficile-Associated Diarrhea 
or CDAD.  

Complications of CDAD may be severe and include pseudomembranous colitis, 
toxic megacolon, sepsis, and death. 

Transmission of C. difficile occurs through oro-fecal route via contaminated 
environment and hands of healthcare workers.

Antimicrobial exposure is the major risk factor for disease as it promotes 
acquisition and growth of C. difficile through suppression of normal bacterial
flora of the colon.

Many studies have shown that use of antimicrobial agents such as clindamycin, 
penicillins, and cephalosporins for the treatment of respiratory infections and 
other unrelated conditions have been associated with development CDAD.

## C. difficile Definitions

|  | Laboratory collection  | Healthcare facility (HCF) exposure from time of laboratory collection |
| --- | --- | --- |
| Healthcare-onset | ≥3 days after hospital admission |  |
| Community-onset, HCF-associated | <3 days or in outpatient setting | ≤30 days  |
| Community-associated | <3 days or in outpatient setting | no HCF admission or ≥90 days  |
| Indeterminate | <3 days or in outpatient setting | ≤90 but >30 days  |

**Notes:**
Clostridium difficile, ... anaerobic spore-forming bacillus, 
is the most common cause of Clostridium difficile-Associated Diarrhea 
or CDAD.  

Complications of CDAD may be severe and include pseudomembranous colitis, 
toxic megacolon, sepsis, and death. 

Transmission of C. difficile occurs through oro-fecal route via contaminated 
environment and hands of healthcare workers.

Antimicrobial exposure is the major risk factor for disease as it promotes 
acquisition and growth of C. difficile through suppression of normal bacterial
flora of the colon.

Many studies have shown that use of antimicrobial agents such as clindamycin, 
penicillins, and cephalosporins for the treatment of respiratory infections and 
other unrelated conditions have been associated with development CDAD.

## Methods

- Identified positive *C. difficile* toxin assays and cultures in laboratory data sent to BioSense from January 1, 2007 through June 30, 2008
- Searched for *C. difficile* in SNOMED-CT*-coded and text-based reports
- Merged laboratory data with Admission, Discharge, Transfer (ADT) data to determine healthcare setting, patient demographics, and previous healthcare exposures
- De-duplicated data; earliest report kept for each unique patient

- *Systematized Nomenclature of Medicine

**Notes:**
Clostridium difficile, ... anaerobic spore-forming bacillus, 
is the most common cause of Clostridium difficile-Associated Diarrhea 
or CDAD.  

Complications of CDAD may be severe and include pseudomembranous colitis, 
toxic megacolon, sepsis, and death. 

Transmission of C. difficile occurs through oro-fecal route via contaminated 
environment and hands of healthcare workers.

Antimicrobial exposure is the major risk factor for disease as it promotes 
acquisition and growth of C. difficile through suppression of normal bacterial
flora of the colon.

Many studies have shown that use of antimicrobial agents such as clindamycin, 
penicillins, and cephalosporins for the treatment of respiratory infections and 
other unrelated conditions have been associated with development CDAD.

## SNOMED-CT1 Codes from PHIN VADS2

**SNOMED-CT ****	****CodeName**
- _[120953000](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_	Clostridium difficile antibody
- _[423590009](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_	Clostridium difficile colitis
- _[96001009](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile toxin B
- _[404907009](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Toxic megacolon due to Clostridium difficile
- _[186431008](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile infection
- _[121963002](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile antibody assay
- _[121897008](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile detection
- _[5933001](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile
- _[255823007](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile enterotoxin A
- _[310541005](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile toxin A detected
- _[122209009](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile culture
- _[72415005](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile assay
- _[118114008](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile antigen assay
- _[122174009](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile toxin A assay
- _[75332002](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile toxin assay
- _[413047002](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile toxin detection
- _[12671002](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile toxin
- _[117963005](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile toxin A AND B assay
- _[121964008](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=ClostridiumSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_SNOMED-CT&URIConvX=true##)_ 	Clostridium difficile toxin B assay

- 1Systematized Nomenclature of Medicine;  2Vocabulary Access and Distribution System

## LOINC1 Codes from PHIN VADS2

_**Loinc Code   Name**_**	**
- _[20761-3](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Stl Ql Aggl
- _[20762-1](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Stl Ql Aerobe Cul
- _[34712-0](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Stl Ql
- _[563-7](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif XXX Ql Cult
- _[562-9](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Stl Ql Cult
- _[31308-0](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Ab Ser-aCnc
- _[9365-8](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Ab Titr Ser
- _[26697-3](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif IgA Ser-aCnc
- _[26702-1](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif IgG Ser-aCnc
- _[26694-0](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif IgM Ser-aCnc
- _[13957-6](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox A Stl Ql EIA
- _[6359-4](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox A Stl EIA-aCnc
- _[6360-2](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox A XXX EIA-aCnc

_**Loinc Code**__     __**Name**_
- _[34468-9](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox A+B Stl Ql EIA
- _[34713-8](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox A+B Stl Ql
- _[6361-0](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox A+B Ser EIA-aCnc
- _[6362-8](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox A+B Stl Ql CT Tiss Cult
- _[6363-6](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox A+B Stl EIA-aCnc
- _[6364-4](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox A+B XXX EIA-aCnc
- _[33947-3](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&currentView=PHINSPACESharedSPACEVocabulary&ResetSPACESearch=ResetSPACESearch&Search=Search&currentVocabSpace=PHIN&ClearSPACECodeSPACESystems=ClearSPACECodeSPACESystems&searchBy=CodeSPACEorSPACEName&whatToDo=activateAdvancedSearch&containsSearch=cSPACEdif&searchWithin=CodeSPACESystemSPACEConcepts&codeSystem=PH_LOINC&URIConvX=true)_ 	C dif Tox Ab Titr Ser Nt
- _[43055-3](http://www.cdc.gov/PhinVSBrowser/StrutsController.do?currentVersion=0&whatToDo=viewTableResult&currentView=PHINSPACESharedSPACEVocabulary&currentVocabSpace=PHIN&whatToDoState=SearchCOLON1691917TRIPOUND20&URIConvX=true)_ 	C dif Tox Ab Titr Ser
- 10895-1 	C dif Tox B Stl Ql
- 46131-9 	C dif Tox B Stl Ql CT Tiss Cult
- 6365-1 	C dif Tox B Stl EIA-aCnc
- 6366-9 	C dif Tox B XXX EIA-aCnc

- 1Logical Observation Identifiers Names and Codes;  2Vocabulary Access and Distribution System

## Text Reports

| EIA positive for C.difficile toxin
 |
| --- |
| POSITIVE FOR C.DIFFICILE TOXINS A AND/OR B CALLED TO, READ BACK AND CONFIRMED BY KM 03/07/08 1330 BY CAM FINAL 03/07/2008
 |
| C. diff Toxin B SPECIMEN DESCRIPTION STOOL COMMENTS NONE TEST RESULT POSITIVE FOR CLOSTRIDIUM DIFFICILE TOXIN B REPORT STATUS FINAL 03192007
 |
| Soft stool:Positive for Clostridium difficile toxin
 |
| ******* MICROBIOLOGY ******* C. DIFFICILE TOXIN A & B EIA @   ACC#:   COLL D/T:12/31/07 1800 ------------- FINAL REPORT ------------------- 02JAN08 CLOSTRIDIUM DIFFICILE TOXIN A & B POSITIVE .END OF REPORT
 |
| SP 2020 01 RAPID MICROBIOLOGY TESTS --------------- PROCEDURE: CLOSTRIDIUM DIFF TOXIN A/B @           COLLECTED: 03/18/08 0945 SOURCE: STOOL     RECEIVED: 03/18/08 1552 STARTED:  03/18/08 1603 -------FINAL REPORT------------ FINAL REPORT                                 03/18/08 1954 POSITIVE for C. difficile Toxin A and/or Toxin B @ = CLOS DIFF TXN A   |

## Text Reports - Negations

| C.difficile toxins are absent or below the limit of detection
 |
| --- |
| NEGATIVE FOR C.DIFFICILE TOXINS A AND/OR B FINAL 05/24/2008
 |
| ******* MICROBIOLOGY ******* C. DIFFICILE TOXIN A & B EIA @   ACC#:02-xxxxx   COLL D/T:06/18/08 0630 ---------------------- FINAL REPORT ------------------------ 18JUN08 CLOSTRIDIUM DIFFICILE TOXIN A & B NOT DETECTED 
 |
| Clostridium difficile toxin A and/or B not present.  
 |
| No Clostridium difficile toxin detected.
 |
| C. diff Toxin EIA SPECIMEN DESCRIPTION STOOL COMMENTS NONE TEST RESULT CANCELLED REQUEST CANCELLED. THIS TEST EXCEEDED REPLICA LIMIT. SPECIMEN WILL BE HELD 24 HOURS. CALL LAB AT xxx-xxx-xxxx IF NECESSARY. REPORT STATUS FINAL 
 |
| ******* MICROBIOLOGY ******* C. DIFFICILE TOXIN A & B EIA @   ACC#:xx-xxxxxx   COLL D/T:01/05/07 1040 ---------------------- FINAL REPORT ------------------------ 06JAN07 SPECIMEN REJECTED. Testing for C. difficile toxins will only be performed on one specimen within a 24 hour timeframe. Patient account has been credited for this test.  |

## Results:  Characteristics of Patients with C. difficile Laboratory Positive Tests (Jan 1, 2007 – Jun 30, 2008)

| Unique patients with laboratory positive tests | N = 4,203 |
| --- | --- |
| Median (range) age in years | 67 (<1, 101) |
| Females | 54% |
| Laboratory collection setting
     Inpatient
     Outpatient
     Emergency department | 
88%
8%
4% |

## C. difficile Types (N = 4,203)

|  | n (%) |
| --- | --- |
| Healthcare-onset | 1,905 (45%) |
| Community-onset, HCF-associated | 704 (17%) |
| Community-associated* | 1,242 (30%) |
| Indeterminate | 286 (7%) |
| Community-onset, unknown exposure | 66 (1%) |

- * Likely an overestimate since healthcare exposures in other facilities are not
-    captured

## C.difficile Rates by Facility

- HO = Healthcare-onset:  laboratory collection date ≥3 days after hospital admission
- CO = Community-onset, HCF-associated:  laboratory collection date <3 days after hospital admission or in outpatient setting AND hospital admission ≤30 days from time of laboratory collection
- * 17 facilities with ≥20 laboratory positive *C. difficile* reports

**Overall HO rate = 7.6 / 10,000 patient-days**
**Overall HO+CO rate = 10.4 / 10,000 patient-days**

## Age Distribution of Healthcare-onset and Community-associated C. difficile Disease

- Age Distribution of Healthcare-onset and Community-associated *C. difficile* Disease

- HO = Healthcare-onset:  laboratory collection date ≥3 days after hospital admission
- CO = Community-associated:  laboratory collection date <3 days after hospital admission or collection  in outpatient setting AND no HCF admission within 90 days from time of laboratory collection

- 		**HO****	****CA****	****p**
**Median (years)****	****67****	****64****	****<0.01**

## Comparing BioSense to Other Studies

|  | BioSense | Kutty et al.
6 hospitals in N.C. | Dubberke et al
5 hospitals nationwide |
| --- | --- | --- | --- |
| Healthcare-onset
    Proportion
    Rate/10,000 pt-days
    Facility rate range | 
45%
7.6
3.8 – 21.4 | 
42%

1.4 – 16.8 | 
60%
11.4
4.1 – 16.8 |
| Community-associated
     Proportion
 | 
30% | 
20% |  |

- Kutty et al, *Infect Control Hosp Epidemiol* 2007
- Dubberke et al, SHEA 2008, Abstract #377

## Limitations

- Assumed previous healthcare exposures were at the same facility
- No formal validation of the data
- 4% of BioSense visits were missing admission/discharge dates which affects rate calculations

## Discussion

- Identified 4,203 laboratory positive *Clostridium difficile* records from 32 laboratories in 12 states
- Proportion of healthcare-onset cases and overall rates and facility rate ranges were similar to other studies
- Automated data from BioSense appears to be a useful tool in tracking *C. difficile *infections

## Next Steps

- Incorporate other data types in the analysis (e.g., pharmacy data)
- Verify data with sample chart review
- Continue to work with subject matter experts and hospital infection control practitioners to maximize utility of data

## Acknowledgements

- L. Clifford McDonald, MD
- Peter Hicks

## Recommendations for Surveillanceof Clostridium difficile Infection

**Admission**

**Discharge**

**< 4 weeks**

**4-12 weeks**

**HO**

**CO-HCFA**

**Indeterminate**

**CA**

**Time**** **

**48 h**

**> 12 weeks**

*****

- HO: Healthcare-onset
- CO-HCFA: Community-Onset Healthcare facility-associated
- CA: Community-Associated
** *******Depending on whether patient was discharged within previous 4 weeks, CO-HCFA vs. CA
- CDAD Surveillance Working Group.* Infect Control Hosp Epidemiol *2007; 28:140-145