Risk for Asymptomatic Household Transmission of C diff

Risk for Asymptomatic Household Transmission of Clostridioides Difficile Infection Associated With Recently Hospitalized Family Members

Aaron C. Miller; Alan T. Arakkal; Daniel K. Sewell; Alberto M. Segre; Sriram V. Pemmaraju; Philip M. Polgreen

Emerging Infectious Diseases. 2022;28(5):932-939.

Abstract and Introduction

Abstract

We evaluated whether hospitalized patients without diagnosed Clostridioides difficile infection (CDI) increased the risk for CDI among their family members after discharge. We used 2001–2017 US insurance claims data to compare monthly CDI incidence between persons in households with and without a family member hospitalized in the previous 60 days. CDI incidence among insurance enrollees exposed to a recently hospitalized family member was 73% greater than enrollees not exposed, and incidence increased with length of hospitalization among family members. We identified a dose-response relationship between total days of within-household hospitalization and CDI incidence rate ratio. Compared with persons whose family members were hospitalized <1 day, the incidence rate ratio increased from 1.30 (95% CI 1.19–1.41) for 1–3 days of hospitalization to 2.45 (95% CI 1.66–3.60) for >30 days of hospitalization. Asymptomatic C. difficile carriers discharged from hospitals could be a major source of community-associated CDI cases.

Introduction

Clostridioides difficile infection (CDI) is one of the most commonly occurring types of healthcare-associated infection and is predominately associated with hospitals. [1,2] Thus, CDI-related investigations and interventions primarily have focused on hospital settings

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Abstract and Introduction
Methods
Results
Discussion
References

Table 1. Baseline enrollment characteristics of families with multiple infected members using a 60-day exposure window in study of asymptomatic *Clostridioides difficile* transmission among household members, United States*
Characteristics	All enrollees. no. (%)	No. (%) episodes of index CDI diagnosis†	No. (%) cases of possible transmission after family member hospitalization
No. CDI cases	NA	224,818	6,575
No. enrollees	142,125,247 (100)	194,424 (100)	6,453 (100)
Age group at enrollment or CDI diagnosis, y
0–17	47,733,847 (33.6)	19,719 (8.8)	547 (8.3)
18–40	46,634,859 (32.8)	37,259 (16.6)	1,156 (17.6)
41–65	44,039,682 (31.0)	103,430 (46.0)	1,822 (27.7)
>65	3,716,859 (2.6)	64,410 (28.6)	3,050 (46.4)
Sex
M	70,485,475 (49.6)	99,133 (44.1)	2,798 (42.6)
F	71,639,772 (50.4)	125,685 (55.9)	3,777 (57.4)
Family size
2	36,598,138 (25.8)	134,644 (59.9)	4,166 (63.4)
3	29,857,746 (21.0)	36,236 (16.1)	905 (13.8)
4	40,705,784 (28.6)	34,559 (15.4)	839 (12.8)
5	21,536,725 (15.2)	13,517 (6.0)	409 (6.2)
>5	13,426,854 (9.4)	5,862 (2.6)	256 (3.9)

*CDI, Clostridioides difficile infection; NA, not applicable.
†Events occurring ≥60 days before another episode.

Table 2. Bivariate comparisons of unadjusted incidence rates and incidence rate ratios for infection incidence across various patient strata using a 60-day exposure window in study of asymptomatic *Clostridioides difficile* transmission among household members, United States*
Variable	Exposed to previously hospitalized family member ≤60 days			Not exposed to previously hospitalized family member ≤60 days			Unadjusted IRR
Variable	CDI cases	Total enrollee months	CDI incidence†	CDI cases	Total enrollee months	CDI incidence†	Unadjusted IRR
Overall	3,871	69,675,026	5.56	160,779	4,998,101,178	3.22	1.73
Age group, y
0–17	317	24,432,280	1.30	15,615	1,445,786,086	1.08	1.20
18–40	567	19,978,891	2.84	29,718	1,427,785,479	2.08	1.37
41–65	1,193	19,281,059	6.19	74,803	1,868,106,655	4.00	1.55
>65	1,794	5,982,798	29.99	40,643	256,422,958	15.85	1.89
Sex
M	1,698	37,945,564	4.47	67,378	2,488,714,427	2.71	1.65
F	2,173	31,729,463	6.85	93,401	2,509,386,752	3.72	1.84
Outpatient antimicrobial drug use within 60 days
None	2,419	63,230,032	3.83	100,792	4,575,861,567	2.20	1.74
Low-risk drugs	292	2,979,748	9.80	11,944	201,200,918	5.94	1.65
High-risk drugs	1,160	3,465,248	33.48	48,043	221,038,693	21.74	1.54
PPI use within 30 days
N	3,477	68,273,806	5.09	146,185	4,913,346,960	2.98	1.71
Y	394	1,401,221	28.12	14,594	84,754,218	17.22	1.63
Infant age <2 y in family
N	3,489	48,618,765	7.18	151,291	4,597,497,625	3.29	2.18
Y	382	21,056,262	1.81	9,488	400,603,553	2.37	0.76

*IRRs compare CDI incidence among persons exposed to a family member previously hospitalized for ≥1 d relative incidence for to those not exposed to a previously hospitalized family member. The overall incidence rate ratio among those exposed to a previously hospitalized family member relative to those unexposed was 1.73 and was >1 across all strata. CDI, Clostridioides difficile infection; IRR, incidence rate ratio; PPI, proton-pump inhibitor.
†Cases per 100,000 enrollee months.

Table 3. Number of cases and enrollee-months in each exposure bin for total days of household-hospitalization using a 60-day exposure window in study of asymptomatic *Clostridioides difficile* transmission among household members, United States*
No. days family members spent hospitalized	60-day exposure window
No. days family members spent hospitalized	No. CDI cases	Total enrollment months	Incidence†
0	160,267	4,980,648,694	3.22
1–3	2,336	52,798,719	4.42
4–10	1,519	27,457,461	5.53
11–20	315	4,338,929	7.26
21–30	107	1,317,610	8.12
>30	106	1,214,792	8.73

*CDI, Clostridioides difficile infection.
†Cases per 100,000 enrollment months.

Table 4. Results of regression analysis of incidence rate ratio for *Clostridioides difficile* infection using quasi-Poisson model and 60-day exposure window in study of asymptomatic *C. difficile* transmission among household members, United States*
Variable	IRR (95% CI)
No. days member was hospitalized within 60 d
0	Referent
1–3	1.30 (1.19–1.41)
4–10	1.46 (1.32–1.62)
11–20	1.79 (1.43–2.23)
21–30	2.17 (1.48–3.18)
>30	2.45 (1.66–3.60)
Age group, y
0–17	Referent
18–40	1.71 (1.65–1.78)
41–65	2.97 (2.86–3.08)
>65	9.32 (8.92–9.73)
Sex
M	Referent
F	1.30 (1.28–1.33)
Outpatient antimicrobial drug use within 60 d
None	Referent
Low-risk drugs	2.69 (2.59–2.79)
High-risk drugs	8.83 (8.63–9.03)
PPI use within 30 d	2.23 (2.15–2.30)
Infant <2 y in family	1.51 (1.44–1.58)

*Models were adjusted for year, month, and family size. Regression models included an offset for number of enrollment months. Because family hospitalization exposure group was followed for 60 days to identify secondary Clostridioides difficile infection, the length of their enrollment period is 60 days. For the unexposed group, the length of enrollment was the length of a given month. IRR, incident rate ratio; PPI, proton-pump inhibitor.

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Risk for Asymptomatic Household Transmission of Clostridioides Difficile Infection Associated With Recently Hospitalized Family Members

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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