Nearly 8% of infected patients who were readmitted to the hospital were diagnosed with recurrent C. diff, indicating that they had been reinfected in a post-discharge setting or were not entirely cured prior to discharge, study data shows.
Inpatients diagnosed with Clostridium difficile infection, whether acquired in the community or during their hospital stays, were twice as likely to be readmitted within 30 days, according to an analysis of seven Detroit Medical Center health system hospitals.
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"Compared with any other cause for readmissions, which totaled 14.4% of patients returning to the hospital within 30 days, 30.1% of patients previously diagnosed with C. diff were readmitted," says Teena Chopra, MD, assistant professor at Wayne State University and director of infection control and antibiotic stewardship at DMC's Harper University Hospital.
And of those C. diff patients who were readmitted, nearly 8% were readmitted with a diagnosis of recurrent C. diff, indicating the patient had been reinfected in a post-discharge setting, or was not entirely cured prior to discharge, she says.
Chopra's study, published in the American Journal of Infection Control,looked at 51,353 patients discharged in 2012, and focused on 615 patients diagnosed with C. diff.
The study also analyzed the cost of the infections and readmissions to the DMC system and calculated that for every patient discharged with C. diff, the cost was $9,116 and for every C. diff patient who required readmission, $9,553.
This was in part due to longer lengths of stay for the readmitted patients, 10 days for a patient with community acquired infection and 12 days for a hospital-acquired infection, which was 4.4 days and 6.4 days longer, respectively, than for patients readmitted who had not been treated for with C. diff during their initial stay.
"With the Centers for Medicare & Medicaid Services now penalizing hospitals with higher rates of 30-day readmissions up to 3%, which is a lot of money, we need to understand that C. diff is a recurring disease," and also that it is one that can be prevented with greater attention to appropriate use of antibiotics throughout the care continuum, Chopra says.
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"We can and must solve the entire vicious circle of C. diff with appropriate use of antibiotics in the hospital, because antibiotics are the number one risk factor for C. diff," she says.This includes greater attention in physician office practice settings, long-term care facilities and nursing homes to make sure patients are not on antibiotics if they don't need to be, and aren't on them any longer than they must be.
Also, practitioners need to be more diligent about making appropriate antibiotic choices, and of course be equally diligent to observe infection control protocols.
"With frequent transfers of patients from one facility to another, antibiotic stewardship programs should be implemented in every single facility," Chopra says. Patients returning within 30 days, and sometimes as long as 60 days, are relapsing or getting re-infected at home or in another healthcare facility, "often because they are exposed to more antibiotics."
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Antibiotics destroy normal intestinal flora that would fight C. diff, which causes severe diarrhea, fever, loss of appetite and other painful symptoms that may also be fatal. CMS now posts hospitals' C. diff infection rates on Hospital Compare. C. diff also is an increasing focus of the Centers for Disease Control and Prevention, which reported new data in February that assigned blame to multiple care settings, not just hospitals.
Chopra emphasizes that patients who get C. diff infections "tend to be patients who are less mobile, and are sicker to begin with as well. They tend to be mostly older, and have multiple comorbidities. Why they are so often readmitted needs to be explored more [with additional studies]. But the fact is they are coming back with this diagnosis, and that can really be stopped."
If she were to repeat her study now, three years later, Chopra believes there would be similarly high rates of C. diff patients readmitted. "We're seeing a similar trend now, even as I see patients in the hospital. C. diff patientsare coming back and being readmitted."
She cites communication between hospitals and other care settings as an area that could use improvement. At DMC hospitals, Chopra says, individual physicians are being held accountable when patients who were under their care during their index stays are readmitted. "Every few months I'm getting my readmission data, and we're asking 'what went wrong?' And then we give feedback to our team as to what we could have done to decrease these readmissions."
Maybe, she says, a review might see that the patient didn't need to have antibiotics at all, or may have had dosages stopped sooner.