Multicenter Study of the Impact of Community-Onset Clostridium difficile Infection on Surveillance for C. difficile Infection

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To evaluate the impact of cases of community-onset, healthcare facility (HCF)–associated Clostridium difficile infection (CDI) on the incidence and outbreak detection of CDI.


A retrospective multicenter cohort study.


Five university-affiliated, acute care HCFs in the United States.


We collected data (including results of C. difficile toxin assays of stool samples) on all of the adult patients admitted to the 5 hospitals during the period from July 1, 2000, through June 30, 2006. CDI cases were classified as HCF-onset if they were diagnosed more than 48 hours after admission or as community-onset, HCF-associated if they were diagnosed within 48 hours after admission and if the patient had recently been discharged from the HCF. Four surveillance definitions were compared: cases of HCF-onset CDI only (hereafter referred to as HCF-onset CDI) and cases of HCF-onset and community-onset, HCF-associated CDI diagnosed within 30, 60, and 90 days after the last discharge from the study hospital (hereafter referred to as 30-day, 60-day, and 90-day CDI, respectively). Monthly CDI rates were compared. Control charts were used to identify potential CDI outbreaks.


The rate of 30-day CDI was significantly higher than the rate of HCF-onset CDI at 2 HCFs (P < .01). The rates of 30-day CDI were not statistically significantly different from the rates of 60-day or 90-day CDI at any HCF. The correlations between each HCF's monthly rates of HCF-onset CDI and 30-day CDI were almost perfect (ρ range, 0.94–0.99; P < .001). Overall, 12 time points had a CDI rate that was more than 3 standard deviations above the mean, including 11 time points identified using the definition for HCF-onset CDI and 9 time points identified using the definition for 30-day CDI, with discordant results at 4 time points (κ = 0.794; P < .001).


Tracking cases of both community-onset and HCF-onset, HCF-associated CDI captures significantly more CDI cases, but surveillance of HCF-onset, HCF-associated CDI alone is sufficient to detect an outbreak.

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