Temporal trends of inpatient C. difficile infections within the Veterans Health Administration hospitals: An analysis of the effect of molecular testing, time to testing, and mandatory reporting

Background: Clostridium difficile infection (CDI) is a reportable hospital metric associated with significant healthcare expenditures. The epidemiology of CDI is pivotal to the implementation of preventative measures.Objective: To portray temporal CDI trends in Veterans Health Administration (VA) hospitals.Design: A retrospective analysis of veterans who had stool testing for C. difficile.Setting: VA acute-care hospitals within the continental United States.Methods: Data were mined from the VA's Corporate Data Warehouse. CDI is reported per 10,000 patient days.Results: From 2006 to 2016, 472,346 patients had C. difficile testing. Overall, decreases in incidence of total CDI (16.81 to 13.66) and hospital-onset healthcare facility-associated (HO-HCFA) CDI (10.87 to 6.41) were observed. Temporal increases in the incidence of total and HO-HCFA CDI were associated with the increased use of molecular testing (P <.0001). Decreased use of fluoroquinolones (P <.0001), clindamycin (P =.0006), and third-generation cephalosporins (P =.0002) correlated with decreased rates of CDI, but VA mandatory reporting did not influence CDI rates (P =.24). The overall crude 30-day mortality of patients with CDI decreased from 2.17 deaths per 10,000 patient days in 2006 to 1.41 in 2016. The frequency of International Classification of Disease, Ninth/Tenth Revision (ICD-9/10) discharge diagnosis for CDI was 73.3%.Conclusion: Molecular testing was associated with increased incidence of CDI. Controlling CDI is likely multifactorial. Although the VA initiative to report cases of hospital-acquired CDI was not significant in our model, the advent of stewardship programs throughout the VA and reductions in the use of third-generation cephalosporins, fluoroquinolones, and clindamycin were significantly associated with reduced rates of CDI.