Impact of the COVID-19 pandemic on the incidence of healthcare facility-onset Clostridioides difficile infection in hospitalized patients with sepsis: Interrupted time series analysis using Japanese Diagnosis Procedure Combination data

Clostridioides difficile (C. difficile) is a spore-forming anaerobic gram-positive bacillus that is associated with nosocomial diarrhea. It is estimated that there were more than 450,000 cases of C. difficile infection (CDI) and approximately 29,000 C. difficile-associated deaths in the United States in 2011 [1]. Furthermore, the number of cases and deaths is increasing, with an estimated annual medical cost of approximately $150 million [2,3]. The incidence of CDI in recent years in Japan is unknown, as no nationwide CDI surveillance has been conducted. Based on a population-based study conducted in nine Tokyo hospitals, it is estimated that CDI occurs in more than 57,000 hospitalized cases per year in individuals over 50 years old in Japan [4]. C. difficile enters the human body via fecal-oral transmission through contact with healthcare workers, contaminated environments, or medical devices, and colonizes by forming spores. It has been reported that 3–18% of inpatients in acute care hospitals and 4–20% of residents in healthcare facilities have C. difficile [5,6], which progresses to symptomatic diarrhea following exposure to antimicrobial agents or antiulcer drugs [7].

The coronavirus disease 2019 (COVID-19) pandemic is ongoing, with the first case diagnosed in Wuhan, China, in 2019. Since January 2020, multiple cases have been confirmed throughout Japan, and the government has announced states of emergency in response to the pandemic. Although the number of patients is less compared to the United States and some European countries, more than 900,000 patients have been reported, and in Japan, more than 15,000 people have died as of July 2021 [8]. The healthcare workers have enforced wearing masks, hand hygiene, and environmental sanitization to prevent infection. In addition, the visits of patients' families were restricted in many medical facilities and nursing homes. The impact of these infection control measures on various types of nosocomial infections is controversial. While some reports indicate that these infection control measures have resulted in an overall decrease in nosocomial infections, others show an increase in some infections, such as catheter-related bloodstream infections [9,10]. Although several single-center observational studies have been reported, it is unclear whether the pandemic reduced healthcare facility-onset CDI (HO-CDI) [[11], [12], [13]].

C. difficile is resistant to alcohol hygiene; therefore, guidelines recommend aggressive handwashing with soap and running water to prevent transmission [14,15]. Contrarily, a systematic review concludes that hand hygiene alone is not enough; therefore, whether handwashing and hand hygiene can reduce the incidence of HO-CDI is still controversial [16]. Our hypotheses were as follows: (a) HO-CDI was decreased because healthcare workers were becoming more concerned about contracting COVID-19 infection and being more proactive in handwashing than before the pandemic, and (b) The impact of handwashing alone may be evaluated by focusing on patients in general wards, where we can assume that there was little change in contact precautions, including personal protective equipment (PPE) and environmental cleaning, from pre-pandemic levels. This study aimed to learn how to effectively control the spread of C. difficile.

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