Skip to main content
    • Aa
    • Aa

Frequent Hospital Readmissions for Clostridium difficile Infection and the Impact on Estimates of Hospital-Associated C. difficile Burden

  • Courtney R. Murphy (a1), Taliser R. Avery (a2), Erik R. Dubberke (a3) and Susan S. Huang (a1)

Clostridium difficile infection (CDI) is associated with hospitalization and may cause readmission following admission for any reason. We aimed to measure the incidence of readmissions due to CDI.


Retrospective cohort study.


Adult inpatients in Orange County, California, who presented with new-onset CDI within 12 weeks of discharge.


We assessed mandatory 2000–2007 hospital discharge data for trends in hospital-associated CDI (HA-CDI) incidence, with and without inclusion of postdischarge CDI (PD-CDI) events resulting in rehospitalization within 12 weeks of discharge. We measured the effect of including PD-CDI events on hospital-specific CDI incidence, a mandatory reporting measure in California, and on relative hospital ranks by CDI incidence.


From 2000 to 2007, countywide hospital-onset CDI (HO-CDI) incidence increased from 15 per 10,000 to 22 per 10,000 admissions. When including PD-CDI events, HA-CDI incidence doubled (29 per 10,000 in 2000 and 52 per 10,000 in 2007). Overall, including PD-CDI events resulted in significantly higher hospital-specific CDI incidence, although hospitals had disproportionate amounts of HA-CDI occurring postdischarge. This resulted in substantial shifts in some hospitals' rankings by CDI incidence. In multivariate models, both HO and PD-CDI were associated with increasing age, higher length of stay, and select comorbidities. Race and Hispanic ethnicity were predictive of PD-CDI but not HO-CDI.


PD-CDI events associated with rehospitalization are increasingly common. The majority of HA-CDI cases may be occurring postdischarge, raising important questions about both accurate reporting and effective prevention strategies. Some risk factors for PD-CDI may be different than those for HO-CDI, allowing additional identification of high-risk groups before discharge.

Infect Control Hosp Epidemiol 2012;33(1):20-28

Corresponding author
Health Policy Research Institute, 100 Theory Drive, Suite 110, Irvine, CA 92617 (
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

1.DO Meltzer , JW Chung . U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists. J Gen Intern Med 2010;25:453459.

3.RM Klevens , MA Morrison , J Nadle , et al. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007;298:17631771.

4.R Datta , SS Huang . Risk of infection and death due to methicillin-resistant Staphylococcus aureus in long-term carriers. Clin Infect Dis 2008;47:176181.

5.SS Huang , R Piatt . Risk of methicillin-resistant Staphylococcus aureus infection after previous infection or colonization. Clin Infect Dis 2003;36:281285.

6.M Weinberger , EZ Oddone , WG Henderson . Does increased access to primary care reduce hospital readmissions? N Engl J Med 1996;334:14411447.

15.ER Dubberke , AM Butler , KA Reske , et al. Attributable outcomes of endemic Clostridium difficile-associated disease in non-surgical patients. Emerg Infect Dis 2008;14:10311038.

16.M Issa , AN Ananthakrishnan , DG Binion . Clostridium difficile and inflammatory bowel disease. Inflamm Bowel Dis 2008;14:14321442.

21.CP Kelly , C Pothoulakis , JT Lamont . Clostridium difficile colitis. N Engl J Med 1994;330:257262.

26.P Hookman , JS Barkin . Clostridium difficile associated infection, diarrhea and colitis. World J Gastroenterol 2009;15:15541580.

27.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.

28.M Miller , D Gravel , M Mulvey , et al. Healthcare-associated Clostridium difficile infection in Canada: patient age and infecting strain type are highly predictive of severe outcome and mortality. Clin Infect Dis 2010;50:194201.

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

34.CL Leibson , J Needleman , P Buerhaus , et al. Identifying in-hospital venous thromboembolism (VTE): a comparison of claims-based approaches with the Rochester Epidemiology Project VTE cohort. Med Care 2008;46:127132.

35.DM Musher , S Aslam , N Logan . Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis 2005;40:15861590.

38.W Courtenay . Constructions of masculinity and their influence on men's well-being: a theory of gender and health. Soc Sci Med 2000;50:13851401.

39.C Lee , RG Owens . Issues for a psychology of men's health. J Health Psychol 2002;7:209217.

41.ER Dubberke , KA Reske , LC McDonald , VJ Fraser . ICD-9-CM codes and surveillance for Clostridium difficile-associated disease. Emerg Infect Dis 2006;12:15761579.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *