Sara Y Tartof, Mark A Schmidt, Richard Contreras, Frederick J Angulo, Ana Florea, Joanna L Barreras, Judy Donald, Joann Zamparo, Deborah Ling Grant, Elizabeth Shuster, Elisa Gonzalez, Jennifer L Kuntz

Burden of medically-attended diarrhea and outpatient Clostridioides difficile infection among persons in two large integrated healthcare settings, 2016-2021

  • Infectious Diseases
  • Oncology

Abstract Background Identification of Clostridioides difficile infection (CDI) in the community setting is increasing. We describe testing for CDI among patients with medically attended diarrhea (MAD) in the outpatient setting, and the incidence of outpatient CDI. Methods This retrospective cohort study among members ≥18 years of age from Kaiser Permanente Southern California (KPSC) and Northwest (KPNW) from 01/01/2016–12/31/2021. MAD was identified by outpatient diarrheal ICD-10 diagnosis codes, and CDI through positive laboratory results. Outpatient CDI was defined by no hospitalization ≤7 days after specimen collection. Incidence rates (IRs) of outpatient CDI were stratified by select demographic and clinical variables. Outpatient CDI burden 12 months following index date was measured by CDI-associated healthcare visits, and CDI testing and treatment. Results We identified 777,533 MAD episodes; 12.1% (93,964/777,533) were tested for CDI. Of those CDI-tested, 10.8% (10,110/93,964) were positive. Outpatient CDI IR was 51.0 (95% confidence interval [CI]: 49.8–52.2) per 100,000 PY, decreasing from 58.2 (95% CI: 55.7–60.7) in 2016 to 45.7 (43.7–47.8) in 2021. 44.1% (n=4,200) received an antibiotic 30 days prior to index date and 84.1% (n=8,006) CDI were ‘community-associated’ (no hospitalizations 12 weeks prior to index date). 6.7% (n=526) of outpatient CDIs had a CDI-associated hospitalization ≤12 months. Conclusions There was a high incidence of outpatient CDI despite infrequent CDI testing among patients with MAD. The majority of those with outpatient CDI had no recent antibiotic use and no recent hospitalization. Further studies are needed to understand the source and management of medically-attended outpatient CDI.

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