title: The burden of healthcare-associated Clostridium difficile infection in a non-metropolitan setting.
abstract: OBJECTIVE
  Healthcare-associated Clostridium difficile infection (HCA-CDI) remains a major cause of morbidity and mortality in industrialized countries. However, few data exist on the burden of HCA-CDI in multi-site non-metropolitan settings. This study examined the introduction of an antimicrobial stewardship programme (ASP) in relation to HCA-CDI rates, and the effect of HCA-CDI on length of stay (LOS) and hospital costs.
  
  
  METHODS
  A comparative before-and-after intervention study of patients aged ≥16 years with HCA-CDI from December 2010 to April 2016 across the nine hospitals of a non-metropolitan health district in New South Wales, Australia was undertaken. The intervention comprised a multi-site ASP supported by a clinical decision support system, with subsequent introduction of email feedback of HCA-CDI cases to admitting medical officers.
  
  
  METHODS
  HCA-CDI rates, comparative LOS and hospital costs, prior use of antimicrobials and proton pump inhibitors, and appropriateness of CDI treatment.
  
  
  RESULTS
  HCA-CDI rates rose from 3.07 to 4.60 cases per 10,000 occupied bed-days pre-intervention, and remained stable at 4 cases per 10,000 occupied bed-days post-intervention (P=0.24). Median LOS (17 vs six days; P<0.01) and hospital costs (AU$19,222 vs $7861; P<0.01) were significantly greater for HCA-CDI cases (N=91) than for matched controls (N=172). Half of the patients with severe HCA-CDI (4/8) did not receive initial appropriate treatment (oral vancomycin).
  
  
  CONCLUSIONS
  HCA-CDI placed a significant burden on the regional and rural health service through increased LOS and hospital costs. Interventions targeting HCA-CDI could be employed to consolidate the effects of ASPs.
authors.affiliation: Department of Pharmacy, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia; School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia. Electronic address: stuart.bond@health.nsw.gov.au.
authors.forename: S E
authors.initials: SE
authors.lastname: Bond
authors.affiliation: Department of Infectious Diseases, Wollongong Hospital, New South Wales, Australia.
authors.forename: C S
authors.initials: CS
authors.lastname: Boutlis
authors.affiliation: School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia; Division of Medicine, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia.
authors.forename: W W
authors.initials: WW
authors.lastname: Yeo
authors.affiliation: School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Department of Medicine, Shoalhaven District Memorial Hospital, Nowra, New South Wales, Australia.
authors.forename: W A B
authors.initials: WAB
authors.lastname: Pratt
authors.affiliation: Department of Pharmacy, Shoalhaven District Memorial Hospital, Nowra, New South Wales, Australia.
authors.forename: M E
authors.initials: ME
authors.lastname: Orr
authors.affiliation: School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia; Department of Infectious Diseases, Wollongong Hospital, New South Wales, Australia.
authors.forename: S
authors.initials: S
authors.lastname: Miyakis
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D003092:Colitis / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D004363:Drug Utilization / Q000592:standards*; D005260:Female; D017048:Health Care Costs; D006761:Hospitals; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009517:New South Wales / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
keywords: Antimicrobial stewardship programme; Clinical decision support system; Clostridium difficile infection; Healthcare costs; Length of stay