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Assessment of Clostridium difficile–Associated Disease Surveillance Definitions, North Carolina, 2005

  • Preeta K. Kutty (a1) (a2), Stephen R. Benoit (a1), Christopher W. Woods (a3) (a4), Arlene C. Sena (a5) (a6), Susanna Naggie (a3) (a4), Joyce Frederick (a3), John Engemann (a4), Sharon Evans (a4), Brian C. Pien (a4), Shailendra N. Banerjee (a1), Jeffery Engel (a7) and L. Clifford McDonald (a1)...

To determine the timing of community-onset Clostridium difficile–associated disease (CDAD) relative to the patient's last healthcare facility discharge, the association of postdischarge cases with healthcare facility–onset cases, and the influence of postdischarge cases on overall rates and interhospital comparison of rates of CDAD.


Retrospective cohort study for the period January 1, 2005, through December 31, 2005.


Catchment areas of 6 acute care hospitals in North Carolina.


We reviewed medical and laboratory records to determine the date of symptom onset, the dates of hospitalization, and stool C. difficile toxin assay results for patients with CDAD who had diarrhea and positive toxin–assay results. Cases were classified as healthcare facility–onset if they were diagnosed more than 48 hours after admission. Cases were defined as community-onset if they were diagnosed in the community or within 48 hours after admission, and were also classified on the basis of the time since the last discharge: if within 4 weeks, community-onset, healthcare facility–associated (CO-HCFA); if 4-12 weeks, indeterminate exposure; and if more than 12 weeks, community-associated. Pearson's correlation coefficient was used to assess the association between monthly rates of healthcare facility–onset, healthcare facility–associated (HO-HCFA) cases and CO-HCFA cases. We performed interhospital rate comparisons using HO-HCFA cases only and using both HO-HCFA and CO-HCFA cases.


Of 1046 CDAD cases, 442 (42%) were HO-HCFA cases and 604 (58%) were community-onset cases. Of the 604 community-onset cases, 94 (15%) were CO-HCFA, 40 (7%) were of indeterminate exposure, and 208 (34%) community-associated. A modest correlation was found between monthly rates of HO-HCFA cases and CO-HCFA cases across the 6 hospitals (r = 0.63, P<.001). Interhospital rankings changed for 6 of 11 months if CO-HCFA cases were included.


A substantial proportion of community-onset cases of CDAD occur less than 4 weeks after discharge from a healthcare facility, and inclusion of CO-HCFA cases influences interhospital comparisons. Our findings support the use of a proposed definition of healthcare facility–associated CDAD that includes cases that occur within 4 weeks after discharge.

Corresponding author
Division of Healthcare Quality Promotion, MS A-31, 1600 Clifton Rd NE, Atlanta, GA 30333 (
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1. J Pépin , L Valiquette , M Alary , et al.Clostridium difficile–associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ 2004;171:466472.

2. LC McDonald , M Owings , DB Jernigan . Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2001. Emerg Infect Dis 2006;12:409415.

3. L Kyne , MB Hamel , R Polavaram , CP Kelly . Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis 2002;34:346353.

4. VG Loo , L Poirier , MA Miller , et al.A predominantly clonal multi-institutional outbreak of Clostridium difficile–associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:24422449.

5. M Warny , J Pepin , A Fang , et al.Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 2005;366:10791084.

6. LC McDonald , GE Killgore , A Thompson , et al.An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005;353:24332441.

7. LR Hirschhorn , Y Trnka , A Onderdonk , MT Lee , R Platt . Epidemiology of community-acquired Clostridium difficle–associated diarrhea. J Infect Dis 1994;169:127133.

8. T Norén , T Akerlund , E Back , et al.Molecular epidemiology of hospital-associated and community-acquired Clostridium difficile infection in a Swedish county. J Clin Microbiol 2004;42:36353643.

9. S Dial , JA Delaney , AN Barkun , S Suissa . Use of gastric acid–suppressive agents and the risk of community-acquired Clostridium difficile–associated disease. JAMA 2005;294:29892995.

10. JS Garner , WR Jarvis , TG Emori , TC Horan , JM Hughes . CDC definitions for nosocomial infections, 1988. (published correction appears in Am J Infect Control 1988;16:177). Am J Infect Control 1988;16:128140.

14. S Johnson , CR Clabots , FV Linn , MM Olson , LR Peterson , DN Gerding . Nosocomial Clostridium difficile colonization and disease. Lancet 1990;336:97100.

18. LV McFarland , ME Mulligan , RY Kwok , WE Stamm . Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204210.

19. L Kyne , M Warny , A Qamar , CP Kelly . Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med 2000;342:390397.

20. L Kyne , M Warny , A Qamar , CP Kelly . Association between antibody response to toxin A and protection against recurrent Clostridium difficile diarrhoea. Lancet 2001;357:189193.

21. JK Shim , S Johnson , MH Samore , DZ Bliss , DN Gerding . Primary symptomless colonization by Clostridium difficile and decreased risk of subsequent diarrhoea. Lancet 1998;351:633636.

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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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