Time trends and predictors of laboratory-confirmed recurrent and severe Clostridioides difficile infections in Manitoba: a population-based study

Article Figures & Tables

Download figure
Open in new tab
Download powerpoint
Figure 1:
Age-standardized CDI rates in Manitoba, 2005 to 2015. Note: CDI = Clostridioides difficile infection, HCF = health care facility.
Download figure
Open in new tab
Download powerpoint
Figure 2:
Proportion of CDI cases that were community-associated, 2005 to 2015. Note: CDI = Clostridioides difficile infection.
Download figure
Open in new tab
Download powerpoint
Figure 3:
Inpatient status for all incident and recurrent CDI in the 30 days following laboratory confirmation of CDI among those who were outpatients at CDI onset. Note: CDI = Clostridioides difficile infection.

Table 1:

Demographic and clinical characteristics of patients with incident or recurrent CDIs

Characteristic	No. (%) of patients^*
Characteristic	All patients n = 8471	Incident CDI n = 6855	Recurrent CDI n = 1616	p value^†
Sex, male	3549 (41.8)	2905 (42.3)	644(39.8)	0.064
Age, median (IQR), yr	71 (55–82)	70 (53–82)	77 (63–85)	< 0.001
SEFI, median (IQR)	−0.08 (−0.57 to 0.40)	−0.07 (−0.57 to 0.40)	−0.10 (−0.59 to 0.39)	0.30
No. of ambulatory care visits in the year preceding the index CDI, median (IQR)	24 (14–39)	22 (13–37)	30 (20–45)	< 0.001
Charlson Comorbidity Index
0	2339 (27.6)	2033 (29.6)	306 (18.9)	< 0.001
1	1491 (17.6)	1199 (17.4)	292 (18.0)
2	1510 (17.8)	1195 (17.4)	315 (19.4)
≥ 3	3131 (36.9)	2428 (35.4)	703 (43.5)
Diabetes	2434 (28.7)	1956 (28.5)	478 (29.5)	0.41
Renal disease	1522 (17.9)	1208 (17.6)	314 (19.4)	0.091
Inflammatory bowel disease	280 (3.3)	224 (3.2)	56 (3.4)	0.70
Type of index CDI (by location of acquisition)
HCF-onset HCF-associated	3563 (42.0)	2824 (41.1)	739 (45.7)	< 0.001
Community-onset HCF-associated	1469 (17.3)	1133 (16.5)	336 (20.7)
Community-associated	2558 (30.1)	2259 (32.9)	299 (18.5)
Indeterminate	881 (10.4)	639 (9.3)	242 (14.9)

Note: CDI = Clostridioides difficile infection, HCF = health care facility, IQR = interquartile range, SEFI = Socioeconomic Factor Index.
↵* Except where indicated otherwise.
↵† The comparison is between characteristics of those with incident versus recurrent CDI.

Table 2:

Predictors of recurrent CDI among patients with diagnosis of CDI

Covariate	Recurrence type; adjusted HR (95% CI)^*
Covariate	First recurrence^†	Second recurrence^‡
Age, yr (Ref: 18–69 yr)
70–79	1.51 (1.27 to 1.79)	1.61 (1.14 to 2.28)
≥ 80	2.01 (1.72 to 2.34)	2.76 (2.06 to 3.70)
Female sex (v. male)	1.16 (1.02 to 1.32)	0.99 (0.78 to 1.25)
SEFI (Ref: richer v. poorer)	0.92 (0.82 to 1.04)	0.98 (0.78 to 1.23)
CCI (Ref: 0)^§
1	1.23 (1.02 to 1.47)	0.83 (0.57 to 1.20)
2	1.17 (0.96 to 1.42)	1.35 (0.96 to 1.91)
≥ 3	1.18 (0.97 to 1.45)	1.23 (0.84 to 1.78)
Diabetes (v. none)	1.06 (0.91 to 1.23)	1.00 (0.76 to 1.31)
Renal disease (v. none)	1.07 (0.89 to 1.30)	1.17 (0.84 to 1.63)
IBD (v. none)	1.13 (0.79 to 1.63)	0.81 (0.36 to 1.83)
Ambulatory care visits in prior year (v. most)
Least	1.17 (0.96 to 1.43)	1.93 (1.20 to 3.11)
Quartile 2	1.20 (0.97 to 1.48)	1.92 (1.21 to 3.05)
Quartile 3	1.10 (0.88 to 1.38)	2.12 (1.37 to 3.27)
CDI subtype (v. community-associated)
HCF-onset HCF-associated^¶	1.20 (1.02 to 1.42)	1.28 (0.91 to 1.79)
Community-onset HCF-associated	1.25 (1.03 to 1.53)	1.51 (1.03 to 2.21)
Indeterminate	1.18 (0.93 to 1.50)	1.34 (0.86 to 2.11)

Note: CDI = Clostridioides difficile infection, CCI = Charlson Comorbidity Index, CI = confidence interval, HCF = health care facility, HR = hazard ratio, IBD = inflammatory bowel disease, Ref = Reference, SEFI = Socioeconomic Factor Index.
↵* HRs were adjusted for all factors listed in table.
↵† For the first recurrence analysis, we included 5795 incident CDIs with > 14 days follow-up. There were 1021 recurrences (events) and 421 deaths (competing events).
↵‡ For the second recurrence analysis, we included 5558 incident CDIs with > 28 day follow-up. There were 295 recurrences (events) and 500 deaths (competing events).
↵§ Renal disease and diabetes omitted from CCI calculation.
↵¶ In the subgroup analysis of those with HCF-onset HCF-associated CDI (n = 2338), longer hospitalization (> 14 days) before CDI onset was associated with increased risk of both first CDI recurrence (n = 477; HR 1.70 [95% CI 1.40 to 2.06]) as well as the second CDI recurrence (n = 142; HR 1.76 [95% CI 1.23 to 2.52]).

Table 3:

Predictors of severe outcomes among patients with CDI diagnosis^*

Covariate	Adjusted OR (95% CI)^†
Age, yr (Ref: 18–69 yr)
70–79	1.52 (1.22 to 1.89)
≥ 80	2.44 (2.02 to 2.94)
Female sex (v. male)	0.92 (0.79 to 1.08)
SEFI^‡	1.11 (1.02 to 1.20)
CCI (Ref: 0)^§
1	1.88 (1.46 to 2.43)
2	2.06 (1.59 to 2.66)
≥ 3	2.55 (1.97 to 3.30)
Diabetes (v. none)	0.98 (0.81 to 1.18)
Renal disease (v. none)	1.65 (1.34 to 2.02)
IBD (v. none)	0.82 (0.45 to 1.49)
Ambulatory care visits in prior year (v. most)
Least	0.69 (0.52 to 0.92)
Quartile 2	0.80 (0.64 to 1.01)
Quartile 3	0.93 (0.76 to 1.13)
CDI subtype (v. community-associated)
HCF-onset HCF-associated^¶	2.56 (2.02 to 3.25)
Community-onset HCF-associated	1.32 (0.99 to 1.77)
Indeterminate	1.02 (0.71 to 1.49)
Recurrent CDI (v. incident CDI)	0.64 (0.52 to 0.79)

Note: CDI = Clostridioides difficile infection, CCI = Charlson Comorbidity Index, CI = confidence interval, HCF = health care facility, IBD = inflammatory bowel disease, OR = odds ratio, SEFI = Socioeconomic Factor Index.
↵* 831 severe outcomes among 6154 patients diagnosed with CDI.
↵† The ORs were adjusted for all the factors listed in the table.
↵‡ SEFI was handled as a continuous variable.
↵§ Renal disease and diabetes omitted from CCI calculation.
↵¶ In the subgroup analysis of those with HCF-onset HCF-associated CDI, longer stay in hospital (> 17 days) before CDI onset was associated with increased risk of severe outcomes (OR 1.36, 95% CI 1.11 to 1.68); 563 severe outcomes among 2568 individuals.

Table 4:

Predictors of admission to hospital within 6 months for outpatients with CDI^*

Covariate	Adjusted HR (95% CI)^†
Recurrence (Ref: No recurrence)	1.58 (1.31 to 1.91)
Age, yr (Ref: 18–69 yr)
70–79	1.55 (1.25 to 1.92)
≥ 80	1.49 (1.23 to 1.81)
Male sex (v. female)	0.95 (0.81 to 1.11)
SEFI^‡	1.17 (1.07 to 1.27)
CCI (Ref: 0)^§
1	1.54 (1.2 to 1.96)
2	1.35 (1.03 to 1.76)
≥ 3	1.83 (1.43 to 2.36)
CDI subtype (v. community-associated)
Community-onset HCF-associated	1.46 (1.21 to 1.77)
Indeterminate	1.31 (1.05 to 1.63)
Ambulatory care visits in previous year (v. least)
Quartile 2	1.34 (0.99 to 1.82)
Quartile 3	1.84 (1.36 to 2.48)
Most	2.20 (1.6 to 3.02)

Note: CDI = Clostridioides difficile infection, CCI = Charlson Comorbidity Index, CI = confidence interval, HCF = health care facility, HR = hazard ratio, SEFI = Socioeconomic Factor Index.
↵* 307 admissions among 2530 outpatients diagnosed with CDI.
↵† The HRs were adjusted for all the factors listed in the table.
↵‡ SEFI was handled as a continuous variable.
↵§ Renal disease and diabetes omitted from CCI calculation.