Association of Community Factors with Hospital-onset Clostridioides (Clostridium) difficile Infection: A Population Based U.S.-wide Study

Ioannis M. Zacharioudakis, Fainareti N. Zervou, Fadi Shehadeh, Evangelia K. Mylona, Eleftherios Mylonakis

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


Background: Clostridioides (Clostridium) difficile ranks first among the pathogens of hospital-acquired infections with hospital-based preventive strategies being only partially successful in containing its spread. Methods: We performed a spatial statistical analysis to examine the association between population characteristics and parameters of community healthcare practice and delivery with hospital-onset Clostridioides (Clostridium) difficile infection (HO-CDI), using data from the Medicare Hospital Compare, Medicare Provider Utilization Part D, and other databases. Among the areas with the highest HO-CDI rates (“hot spots”), we conducted a geographically weighted regression (GWR) to quantify the effect of the decrease in the modifiable risk factors on the HO-CDI rate. Findings: Percentage of population > 85 years old, community claims of antimicrobial agents and acid suppressants, and density of hospitals and nursing homes within the hospital service areas (HSAs) had a statistically significant association with the HO-CDI incidence (p < 0.001). The model including the community claims of antimicrobial agents and number of hospital centers per HSA km2 was associated with 10% (R2 = 0.10, p < 0.001) of the observed variation in HO-CDI rate. The hot spots were organized into 5 Combined Statistical areas that crossed state borders. The association of the antimicrobial claims and HO-CDI rate was as high as 71% in the Boston–Worcester–Providence area (R2 = 0.71, SD 0.19), with a 10% decrease in the rate of antimicrobial claims having the potential to lead to up to 23.1% decrease in the HO-CDI incidence in this area. Interpretation: These results outline the association of HO-CDI with community practice and characteristics of the healthcare delivery system and support the need to further study the effect of community and nursing home-based antimicrobial and acid suppressant stewardship programs in the rate of HO-CDI in geographic areas that may cross state lines.

Original languageEnglish (US)
Pages (from-to)12-19
Number of pages8
StatePublished - Feb 2019


  • Clostridioides difficile
  • Clostridium difficile
  • Geographically weighted regression model
  • HO-CDI
  • Risk factors
  • Spatial statistical analysis

ASJC Scopus subject areas

  • Medicine(all)


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