On January 30, 2020, the World Health Organization (WHO) Director-General declared that the COVID-19 outbreak constituted a Public Health Emergency of International Concern.1 During the initial phase of the COVID-19 pandemic, hospitals completely transformed their activity to provide care to patients with SARS-CoV-2 infection. The pandemic period led to a dramatic increase in infection control measures, a significant reduction in surgical activity, and possibly modifications in antimicrobial prescription patterns.2–4 We hypothesized that all these factors could have contributed to significant changes in Clostridioides difficile epidemiology. Therefore, we carried out a retrospective study to assess the trends in C. difficile infections and their association with antimicrobial usage and surgical activity at our institution.
Our hospital is a 250-bed facility on the East Coast of Spain that belongs to the National Health System and provides care to 190,000 inhabitants. The first cases of COVID-19 were diagnosed at our institution on March 13, 2020. We reviewed the records from the Clinical Microbiology, Pharmacy departments, and hospital administrative data from January 1, 2020, to December 31, 2022. We estimated the rates of C. difficile infections, surgical activity (elective and emergency interventions with general anesthesia), and antimicrobial usage in daily defined doses (DDD). C. difficile infection was identified in stool samples using polymerase chain reaction (PCR) systems either with FilmArray Gastrointestinal Panel (Biofire Diagnostics, LLC, Salt Lake City, Utah, USA), or GeneXpert System (Xpert© C. difficile BT. Cepheid AB, Solna, Sweden).
In the study period, 164 patients, mean age 61.1 years [range three months to 96 years], 42% males, had C. difficile infection. There were no cases of C. difficile infections due to ribotype 027. C. difficile infections per 10,000 admissions rose from 2020 to 2022, starting from 18.03, 41.40, and finishing at 72.3, respectively (Table 1). Compared with the following year, the prevented fraction for C. difficile in 2020 was 56.44% (95% Confidence interval: 27.59–73.79%, P < .001). There were no significant reductions in surgical activity rates (P = .17) or antimicrobial consumption rates (P = .30) between the years 2020 and 2021 (Table 1).
Trends in C. difficile hospital infections, surgical activity and antimicrobial usage 2020-2022.
| Year | Hospital admissions | COVID-19 cases | No. of stool samples | C.difficile cases | C difficile per 10,000 admissions | C difficile per 1000 stool samples | No. of elective surgery | No. of emergency surgery | Antimicrobial usage |
|---|---|---|---|---|---|---|---|---|---|
| Total DDD | |||||||||
| 2020 | 11,643 | 568 | 1568 | 21 | 18 | 13 | 3428 | 1472 | 9689.36 |
| 2021 | 12,317 | 906 | 1907 | 51 | 41 | 27 | 3791 | 1535 | 10,101.95 |
| 2022 | 12,724 | 916 | 1923 | 92 | 72 | 48 | 4520 | 1569 | 10,386.96 |
DDD: daily defined dose.
However, C. difficile infections occurred more often in patients with COVID-19 than in subjects admitted to the hospital due to other conditions. In the study period, a total of 20 out of 2390 patients with COVID-19 had C. difficile infection (83.68 per 10,000 admissions), whereas, in patients with no COVID-19 infection, the incidence rate was 41.98 per 10,000 admissions (RR 1.83; 95% Confidence interval: 1.15–2.92; P = 0.009).
According to our hypotheses, we have observed that strict infection control measures taken in 2020 had a significant impact on C. difficile infections. Studies examining C. difficile infection trends during COVID-19 epidemics showed discrepant results. Some studies showed a reduction in C. difficile rates related to infection control strategies,5,6 others did not report significant changes,7 and some demonstrated an increase in C. difficile rates.8 Neither of the studies reported surgical activity information during the study periods. However, all of them showed greater use of antimicrobials during COVID-19 waves. Regarding the specific susceptibility of patients with COVID-19 to acquire C. difficile infection, a study reported an increased risk by a factor of two, likewise to our report.9 A case-control study identified steroid use, hospitalization in the last two months, and receiving antimicrobials during the hospital stay as the independent factors associated with C. difficile infection in patients with COVID-19.10
Our study has some limitations. Firstly, data were generated from a secondary-level hospital instead of a tertiary care facility. Secondly, data were obtained from a hospital in Spain, and the results would not be generalizable to other countries. Nevertheless, we consider there was a small risk of internal bias, and our results could be extrapolated to centers with similar characteristics.
In summary, infection control measures, like enhanced hand hygiene, isolation precautions, use of personal protection equipment, and environmental cleaning, helped to minimize cross-transmission and contributed to reducing C. difficile rates during the first pandemic wave.
