Skip to main content
    • Aa
    • Aa

Hospital Transfer Network Structure as a Risk Factor for Clostridium difficile Infection

  • Jacob E. Simmering (a1), Linnea A. Polgreen (a1), David R. Campbell (a2), Joseph E. Cavanaugh (a3) and Philip M. Polgreen (a4)...

To determine the effect of interhospital patient sharing via transfers on the rate of Clostridium difficile infections in a hospital.


Retrospective cohort.


Using data from the Healthcare Cost and Utilization Project California State Inpatient Database, 2005–2011, we identified 2,752,639 transfers. We then constructed a series of networks detailing the connections formed by hospitals. We computed 2 measures of connectivity, indegree and weighted indegree, measuring the number of hospitals from which transfers into a hospital arrive, and the total number of incoming transfers, respectively. Next, we estimated a multivariate model of C. difficile infection cases using the log-transformed network measures as well as covariates for hospital fixed effects, log median length of stay, log fraction of patients aged 65 or older, and quarter and year indicators as predictors.


We found an increase of 1 in the log indegree was associated with a 4.8% increase in incidence of C. difficile infection (95% CI, 2.3%–7.4%) and an increase of 1 in log weighted indegree was associated with a 3.3% increase in C. difficile infection incidence (1.5%–5.2%). Moreover, including measures of connectivity in our models greatly improved their fit.


Our results suggest infection control is not under the exclusive control of a given hospital but is also influenced by the connections and number of connections that hospitals have with other hospitals.

Infect. Control Hosp. Epidemiol. 2015;36(9):1031–1037

Corresponding author
Address correspondence to Philip M. Polgreen, MD, MPH, Departments of Epidemiology and Internal Medicine, University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242 (
Hide All

Presented in part: IDWeek 2013; San Francisco, California; October 5, 2013 (abstract 1214); and the 5th Biennial Conference of the American Society of Health Economists; University of Southern California; Los Angeles, CA; June 23, 2014; and the Midwest Social and Administrative Pharmacy Conference; Purdue University; Lafayette, IN; July 17, 2014.

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.

2. LC McDonald , M Owings , DB Jernigan . Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996–2003. Emerg Infect Dis 2006;12:409.

4. RR Campbell , D Beere , GK Wilcock , EM Brown . Clostridium difficile in acute and long-stay elderly patients. Age Ageing 1988;17:333336.

7. V Stevens , G Dumyati , LS Fine , SG Fisher , E van Wijngaarden . Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis 2011;53:4248.

9. J Wistrom , SR Norrby , EB Myhre , et al. Frequency of antibiotic-associated diarrhoea in 2462 antibiotic-treated hospitalized patients: a prospective study. J Antimicrob Chemother 2001;47:4350.

10. MJ Gurwith , HR Rabin , K Love . Diarrhea associated with clindamycin and ampicillin therapy: preliminary results of a cooperative study. J Infect Dis 1977;135:S104S110.

11. KA Brown , N Khanafer , N Daneman , DN Fisman . Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother 2013;57:23262332.

13. VG Loo , AM Bourgault , L Poirier , et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med 2011;365:16931703.

14. DJ Weber , D Anderson , WA Rutala . The role of the surface environment in healthcare-associated infections. Curr Opin Infect Dis 2013;26:338344.

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

19. UH Karkada , LA Adamic , JM Kahn , TJ Iwashyna . Limiting the spread of highly resistant hospital-acquired microorganisms via critical care transfers: a simulation study. Intensive Care Med 2011;37:16331640.

21. M Ciccolini , T Donker , H Grundmann , MJ Bonten , ME Woolhouse . Efficient surveillance for healthcare-associated infections spreading between hospitals. Proc Natl Acad Sci U S A 2014;111:22712276.

23. T Donker , J Wallinga , H Grundmann . Patient referral patterns and the spread of hospital-acquired infections through national health care networks. PLoS Comput Biol 2010;6:e1000715.

24. VD Blondel , J-L Guillaume , R Lambiotte , E Lefebvre . Fast unfolding of communities in large networks. J Stat Mech 2008;2008:P10008.

27. RP Hobson , FM MacKenzie , IM Gould . An outbreak of multiply-resistant Klebsiella pneumoniae in the Grampian region of Scotland. J Hosp Infect 1996;33:249262.

28. T Svoboda , B Henry , L Shulman , et al. Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto. N Engl J Med 2004;350:23522361.

29. DE Curtis , CS Hlady , G Kanade , SV Pemmaraju , PM Polgreen , AM Segre . Healthcare worker contact networks and the prevention of hospital-acquired infections. PLoS One 2013;8:e79906.

33. JL Kuntz , PM Polgreen . The importance of considering different healthcare settings when estimating the burden of Clostridium difficile. Clin Infect Dis 2015;60:831836.

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? *


Full text views

Total number of HTML views: 8
Total number of PDF views: 86 *
Loading metrics...

Abstract views

Total abstract views: 264 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 22nd September 2017. This data will be updated every 24 hours.