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Epidemiological Model for Clostridium difficile Transmission in Healthcare Settings

  • C. Lanzas (a1) (a2), E. R. Dubberke (a3), Z. Lu (a1), K. A. Reske (a3) and Y. T. Gröhn (a1)...

Recent outbreaks of Clostridium difficile infection (CDI) have been difficult to control, and data indicate that the importance of different sources of transmission may have changed. Our objectives were to evaluate the contributions of asymptomatic and symptomatic C. difficile carriers to new colonizations and to determine the most important epidemiological factors influencing C. difficile transmission.

Design, Setting, and Patients.

Retrospective cohort study of all patients admitted to medical wards at a large tertiary care hospital in the United States in the calendar year 2008.


Data from six medical wards and published literature were used to develop a compartmental model of C. difficile transmission. Patients could be in one of five transition states in the model: resistant to colonization (R), susceptible to colonization (S), asymptomatically colonized without protection against CDI (C-), asymptomatically colonized with protection against CDI (C+), and diseased (ie, with CDI; D).


The contributions of C-, C+, and D patients to new colonizations were similar. The simulated basic reproduction number ranged from 0.55 to 1.99, with a median of 1.04. These values suggest that transmission within the ward alone from patients with CDI cannot sustain new C. difficile colonizations and therefore that the admission of colonized patients plays an important role in sustaining transmission in the ward. The epidemiological parameters that ranked as the most influential were the proportion of admitted C- patients and the transmission coefficient for asymptomatic carriers.


Our study underscores the need to further evaluate the role of asymptomatically colonized patients in C. difficile transmission in healthcare settings.

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2. LC McDonald , GE Killgore , A Thompson , et al.An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005;353(23):24332441.

3. JA O'Brien , BJ Lahue , JJ Caro , DM Davidson . The emerging infectious challenge of Clostridium difficile-associated disease in Massachusetts hospitals: clinical and economic consequences. Infect Control Hosp Epidemiol 2007;28(11):12191227.

4. ER Dubberke , AM Butler , KA Reske , et al.Attributable outcomes of endemic Clostridium difficile-associated disease in nonsurgical patients. Emerg Infect Dis 2008;14(7):103l1038.

5. LC McDonald , M Owings , DB Jernigan . Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis 2006;12(3):409415.

6. L Valiquette , B Cossette , MP Garant , H Diab , J Pépin . Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007;45(suppl 2):S112S121.

7. LV McFarland , ME Mulligan , RY Kwok , WE Stamm . Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320(4):204210.

8. MH Samore , L Venkataraman , PC DeGirolami , RD Arbeit , AW Karchmer . Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 1996;100(1):3240.

9. CR Clabots , S Johnson , MM Olson , LR Peterson , DN Gerding . Acquisition of Clostridium difficile by hospitalized patients: evidence for colonized new admissions as a source of infection. J Infect Dis 1992;166(3):561567.

11. LV McFarland , HW Beneda , JE Clarridge , GJ Raugi . Implications of the changing face of Clostridium difficile disease for health care practitioners. Am J Infect Control 2007;35(4):237253.

15. DJ Austin , MJM Bonten , RA Weinstein , S Slaughter , RM Anderson . Vancomycin-resistant enterococci in intensive-care hospital settings: transmission dynamics, persistence, and the impact of infection control programs. Proc Natl Acad Sci USA 1999;96(12): 69086913.

16. EMC D'Agata , G Webb , M Horn . A mathematical model quantifying the impact of antibiotic exposure and other interventions ori the endemic prevalence of vancpmycin-resistant enterococci. J Infect Dis 2005;192(11):20042011.

17. MCJ Bootsma , O Diekmann , MJM Bonten . Controlling methi-cillin-resistant Staphylococcus aureus: quantifying the effects of interventions and rapid diagnostic testing. Proc Natl Acad Sci USA 2006;103(14):56205625.

18. JM Starr , A Campbell , E Renshaw , IR Poxton , GJ Gibson . Spatio-temporal stochastic modelling of Clostridium difficile. J Hosp Infect 2009;71(1):4956.

19. J McCoubrey , J Starr , H Martin , IR Poxton . Clostridium difficile in a geriatric unit: a prospective epidemiological study employing a novel S-layer typing method. J Med Microbiol 2003;52(7): 573578.

20. S Johnson , DN Gerding . Clostridium difficile-associated diarrhea. Clin Infect Dis 1998;26(5):10271034.

21. S Johnson , SR Homann , KM Bettin , et al.Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole: a randomized, placebo-controlled trial. Ann Intern Med 1992;117(4):297302.

23. 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(6):390397.

24. LV McFarland . Update on the changing epidemiology of Clostridium difficile-associated disease. Nat Clin Pract Gastroenterol Hepatol 2008;5(1):4048.

27. IM Sobol' . Global sensitivity indices for nonlinear mathematical models and their Monte Carlo estimates. Math Comput Simul 2001;55(1-3):271280.

29. EJ Kuijper , B Coignard , P Tüll . Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2006;12(suppl s6):218.

30. ER Dubberke . The A, B, BI, and Cs of Clostridium difficile. Clin Infect Dis 2009;49(8):11481152.

31. MH Wilcox , L Mooney , R Bendall , CD Settle , WN Fawley . A case-control study of community-associated Clostridium difficile infection. J Antimicrob Chemother 2008;62(2):388396.

32. JS Weese . Clostridium difficile in food: innocent bystander or serious threat? Clin Microbiol Infect 2010;16(1):310.

35. S Johnson , DN Gerding , MM Olson , et al.Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med 1990;88(2):137140.

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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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