Incidence, Attributable Mortality, and Healthcare and Out-of-Pocket Costs of Clostridioides difficile Infection in US Medicare Advantage Enrollees.

BACKGROUND: US attributable Clostridioides difficile infection (CDI) mortality and cost data are primarily from Medicare fee-for-service populations, and little is known about Medicare Advantage Enrollees (MAEs). This study evaluated CDI incidence among MAEs from 2012 to 2019 and determined attributable mortality and costs by comparing MAEs with and without CDI occurring in 2018. METHODS: This retrospective cohort study assessed CDI incidence and associated mortality and costs for eligible MAEs ≥65 years of age using the de-identified Optum Clinformatics Data Mart database (Optum; Eden Prairie, Minnesota, USA). Outcomes included mortality, healthcare utilization, and costs, which were assessed via a propensity score-matched cohort using 2018 as the index year. Outcome analyses were stratified by infection acquisition and hospitalization status. RESULTS: From 2012 to 2019, overall annual CDI incidence declined from 609 to 442 per 100 000 person-years. Although the incidence of healthcare-associated CDI declined overall (2012, 53.2%; 2019, 47.2%), community-associated CDI increased (2012, 46.8%; 2019, 52.8%). The 1-year attributable mortality was 7.9% (CDI cases, 26.3%; non-CDI controls, 18.4%). At the 2-month follow-up, CDI-associated excess mean total healthcare and out-of-pocket costs were $13 476 and $396, respectively. Total excess mean healthcare costs were greater among hospitalized (healthcare-associated, $28 762; community-associated, $28 330) than nonhospitalized CDI patients ($5704 and $2320, respectively), whereas total excess mean out-of-pocket cost was highest among community-associated hospitalized CDI patients ($970). CONCLUSIONS: CDI represents an important public health burden in the MAE population. Preventive strategies and treatments are needed to improve outcomes and reduce costs for healthcare systems and this growing population of older US adults.

Costs Attributable to Clostridioides difficile Infection Based on the Setting of Onset.

BACKGROUND: Although hospital-onset Clostridioides difficile infection (CDI) is associated with significant healthcare costs, the economic burden of CDI with onset in other facilities or the community has not been well studied. METHODS: Incident CDI cases were identified using 2011-2017 Medicare fee-for-service data. Controls were randomly selected in a 4:1 ratio matching to the CDI case surveillance definition. Inverse probability of exposure weights were used to balance on measured confounders. One-, 3-, and 5-year cumulative costs attributable to CDI were computed using a 3-part estimator (parametric survival model and pair of 2-part models predicting costs separately in intervals where death did and did not occur). RESULTS: A total of 60 492 CDI cases were frequency-matched to 241 968 controls. One-, 3-, and 5-year adjusted attributable costs were highest for hospital-onset CDI at $14 257, $18 953, and $21 792, respectively, compared with hospitalized controls and lowest for community-associated CDI compared with community controls at $1013, $3161, and $6454, respectively. Adjusted 1-, 3-, and 5-year costs attributable to community-onset healthcare facility-associated CDI were $8222, $13 066, and $16 329 and for other healthcare facility-onset CDI were $5345, $6764, and $7125, respectively. CONCLUSIONS: Economic costs attributable to CDI in elderly persons were highest for hospital-onset and community-onset healthcare facility-associated CDI. Although lower, attributable costs due to CDI were significantly higher in cases with CDI onset in the community or other healthcare facility than for comparable persons without CDI. Additional strategies to prevent CDI in the elderly are needed to reduce morbidity and healthcare expenditures.

Incidence of Staphylococcus aureus Infections After Elective Surgeries in US Hospitals.

BACKGROUND: Although Staphylococcus aureus is a leading cause of postsurgical infections, national estimates of these infections after elective surgeries based on microbiology data are limited. This study assessed cumulative 180-day postsurgical S. aureus incidence in real-world hospital settings. METHODS: A retrospective study of adults (≥18 years) undergoing inpatient or hospital-based outpatient elective surgeries from 1/7/2010-30/6/2015 at hospitals (N = 181) reporting microbiology results in the Premier Healthcare Database (PHD). 86 surgical categories were identified from the National Healthcare Safety Network procedures. We classified positive S. aureus cultures using a hierarchy (bloodstream [BSI], surgical site [SSI], and all other types [urinary tract, respiratory, other/unknown site]) and calculated incidence (number of infections divided by the number of elective surgery discharges). We estimated national infection case volumes by multiplying incidence by national inpatient elective surgical discharge estimates using the entire PHD and weights based on hospital characteristics. RESULTS: Following 884 803 inpatient elective surgical discharges, 180-day S. aureus infection incidence was 1.35% (0.30% BSI, 0.74% SSI no BSI, 0.32% all other types only). Among 1 116 994 hospital-based outpatient elective surgical discharges, 180-day S. aureus incidence was 1.19% (0.25% BSI, 0.75% SSI no BSI, 0.19% all other types only). Methicillin resistance was observed in ~45% of the S. aureus infections. We estimated 55 764 S. aureus postsurgical infections occurred annually in the US following 4.2 million elective inpatient surgical discharges. CONCLUSIONS: The high burden of S. aureus infections after both inpatient and outpatient elective surgeries highlights the continued need for surveillance and novel infection prevention efforts.

Burden of Staphylococcus aureus infections after orthopedic surgery in Germany.

BACKGROUND: This study assessed incidence, risk factors, and outcomes of Staphylococcus aureus infections (SAI) following endoprosthetic hip or knee, or spine surgeries. METHODS: Adult patients with at least one of the selected surgeries from 2012 to 2015 captured in a German sickness fund database were included. SAI were identified using S. aureus-specific ICD-10 codes. Patients with certain prior surgeries and infections were excluded. Cumulative incidence and incidence density of post-surgical SAI were assessed. Risk factors, mortality, healthcare resource utilization and direct costs were compared between SAI and non-SAI groups using multivariable analyses over the 1 year follow-up. RESULTS: Overall, 74,327 patients who underwent a knee (28.6%), hip (39.6%), or spine surgery (31.8%) were included. The majority were female (61.58%), with a mean age of 69.59 years and a mean Charlson Comorbidity Index (CCI) of 2.3. Overall, 1.92% of observed patients (20.20 SAI per 1000 person-years (PY)) experienced a SAI within 1 year of index hospitalization. Knee surgeries were associated with lower SAI risk compared with hip surgeries (Hazard Ratio (HR) = 0.8; p = 0.024), whereas spine surgeries did not differ significantly from hip surgeries. Compared with non-SAI group, the SAI group had on average 4.4 times the number of hospitalizations (3.1 vs. 0.7) and 7.7 times the number of hospital days (53.5 vs. 6.9) excluding the index hospitalization (p < 0.001). One year post-orthopedic mortality was 22.38% in the SAI and 5.31% in the non-SAI group (p < 0.001). The total medical costs were significantly higher in the SAI group compared to non-SAI group (42,834€ vs. 13,781€; p < 0.001). Adjusting for confounders, the SAI group had nearly 2 times the all-cause direct healthcare costs (exp(b) = 1.9; p < 0.001); and 1.72 times higher risk of death (HR = 1.72; p < 0.001). CONCLUSIONS: SAI risk after orthopedic surgeries persists and is associated with significant economic burden and risk of mortality. Hence, risk reduction and prevention methods are of utmost importance.

Synthesis of novel multifunctional carbazole-based molecules and their thermal, electrochemical and optical properties.

Two novel carbazole-based compounds 7a and 7b were synthesised as potential candidates for application in organic electronics. The materials were fully characterised by NMR spectroscopy, mass spectrometry, FTIR, thermogravimetric analysis, differential scanning calorimetry, cyclic voltammetry, and absorption and emission spectroscopy. Compounds 7a and 7b, both of which were amorphous solids, were stable up to 291 °C and 307 °C, respectively. Compounds 7a and 7b show three distinctive absorption bands: high and mid energy bands due to locally excited (LE) transitions and low energy bands due to intramolecular charge transfer (ICT) transitions. In dichloromethane solutions compounds 7a and 7b gave emission maxima at 561 nm and 482 nm with quantum efficiencies of 5.4% and 97.4% ± 10%, respectively. At positive potential, compounds 7a and 7b gave two different oxidation peaks, respectively: quasi-reversible at 0.55 V and 0.71 V, and reversible at 0.84 V and 0.99 V. At negative potentials, compounds 7a and 7b only exhibited an irreversible reduction peak at -1.86 V and -1.93 V, respectively.

Impaired Quality of Life, Work, and Activities Among Adults with Clostridium difficile Infection: A Multinational Survey.

BACKGROUND: Evidence of humanistic detriments of Clostridium difficile infection (CDI) remains limited. AIMS: To assess humanistic burden associated with CDI. METHODS: Self-reported National Health and Wellness Survey data between 2013 and 2016 were analyzed for the USA, five European countries, China, and Brazil. Outcome measures included SF-36v2® for health-related quality of life (HRQoL) and Work Productivity and Activity Impairment questionnaire. Respondents (≥ 18 years old) were classified as (1) currently treated doctor-diagnosed CDI (C-CDI), (2) doctor-diagnosed prior CDI (P-CDI), or (3) never experienced CDI (NO-CDI). Regression modeling assessed the association between CDI status and outcomes, adjusting for potential confounders. RESULTS: Of 352,780 respondents, 299, 2111, and 350,370 met the criteria for C-CDI, P-CDI, and NO-CDI, respectively, with 45% of the total from the USA. C-CDI and P-CDI respondents were older, were less often employed and had more comorbidities than those with NO-CDI. After adjustment for covariates, C-CDI and P-CDI had significantly lower HRQoL relative to NO-CDI for mental (MCS 39, 43 vs. 46) and physical (PCS 39, 41 vs. 46) component summary scores, and health utility (SF-6D 0.58, 0.64 vs. 0.71) (all p < 0.05), meeting common thresholds for minimally important differences. Those with C-CDI and P-CDI reported missing more work (21, 16 vs. 8%), greater impairment while working (43, 34 vs. 22%), and more activity impairment (61, 49 vs. 34%) than those with NO-CDI (all p < 0.05), respectively. CONCLUSIONS: CDI is associated with meaningfully worse HRQoL and greater impairment to work and activities compared with NO-CDI. The impairment directly attributable to CDI requires further evaluation.

Detection of 2,4,6-Trinitrotoluene Using a Miniaturized, Disposable Electrochemical Sensor with an Ionic Liquid Gel-Polymer Electrolyte Film.

A new electrochemical method to detect and quantify the explosive compound 2,4,6-trinitrotoluene (TNT) in aqueous solutions is demonstrated. A disposable thin-film electrode modified with a droplet of a gel-polymer electrolyte (GPE) was immersed directly into samples of TNT at concentrations of 1-10 µg/mL. The GPE contained the hydrophobic room-temperature ionic liquid (RTIL) trihexyltetradecylphosphonium bis(trifluoromethylsulfonyl)imide ([P14,6,6,6][NTf2]) and the polymer poly(hexyl methacrylate). The RTIL acted to preconcentrate TNT into the GPE and provided ionic conductivity. The polymer provided both (i) sufficient viscosity to ensure mechanical stability of the GPE and (ii) strong hydrophobicity to minimize leaching of the RTIL. Square wave voltammetry was performed on the first reduction peak of TNT-preconcentrated samples (15 min soaking with mechanical stirring), with linear plots of peak current vs cumulative concentration of TNT, giving an averaged limit of detection of 0.37 µg/mL (aqueous phase concentration). Additionally, the voltammetry of the first reduction peak of TNT in [P14,6,6,6][NTf2] was unaffected by the presence of oxygen-in contrast to that observed in an imidazolium-based RTIL-providing excellent selectivity over oxygen in real environments. The sensor device was able to quickly and easily quantify TNT concentrations at typical ground water contamination levels. The low-cost and portability of the sensor device, along with the minimal amounts of GPE materials required, make this a viable platform for the onsite monitoring of explosives, which is currently a significant operational challenge.

Investigating TNT loss between sample collection and analysis.

Explosives residues are often collected from explosion scenes, and from surfaces suspected of being in contact with explosives, by swabbing with solvent-wetted cotton swabs. It is vital that any explosives traces present on the swabs are successfully extracted and detected when received in a laboratory. However, a 2007 proficiency test initiated by the European Network of Forensic Science Institutes (ENFSI) Expert Working Group on Explosives involving TNT-spiked cotton swabs highlighted that explosives may not always be detected from such samples. This paper outlines work performed to determine potential reasons for this finding. Cotton swabs were spiked using a solution of TNT and stored in nylon bags and glass vials for periods of 1, 2 and 4weeks. Simulated swab extracts were also prepared and investigated. The samples were stored in a freezer, or at room temperature either in the dark or exposed to daylight. Overall, the cotton swabs stored at room temperature and exposed to daylight showed a very rapid loss of TNT over time, whereas cotton swabs stored in the freezer, and all simulated swab extracts, gave high recoveries over time. These results will be of benefit for practicing forensic explosives laboratories and for persons undertaking cold-case reviews involving explosive-based samples.

Burden of Clostridium difficile-associated disease among patients residing in nursing homes: a population-based cohort study.

BACKGROUND: Clostridium difficile (C. difficile) infection (CDI) is the leading cause of nosocomial diarrhea in the United States. This study aimed to examine the incidence of CDI and evaluate mortality and economic burden of CDI in an elderly population who reside in nursing homes (NHs). METHODS: This was a population-based retrospective cohort study focusing on US NHs by linking Medicare 5% sample, Medicaid, Minimum Data Set (MDS) (2008-10). NH residents aged ≥65 years with continuous enrollment in Medicare and/or Medicaid Fee-for-Service plan for ≥12 months and ≥2 quarterly MDS assessments were eligible for the study. The incidence rate was calculated as the number of CDI episodes by 100,000 person-years. A 1:4 propensity score matched sample of cohorts with and without CDI was generated to assess mortality and health care costs following the first CDI. RESULTS: Among 32,807 NH residents, 941 residents had ≥1 episode of CDI in 2009, with an incidence of 3359.9 per 100,000 person-years. About 30% CDI episodes occurred in the hospital setting. NH residents with CDI (vs without CDI) were more likely to have congestive heart failure, renal disease, cerebrovascular disease, hospitalizations, and outpatient antibiotic use. During the follow-up period, the 30-day (14.7% vs 4.3%, P < 0.001), 60-day (22.7% vs 7.5%, P < 0.001), 6-month (36.3% vs 18.3%, P < 0.001), and 1-year mortality rates (48.2% vs 31.1%, P < 0.001) were significantly higher among the CDI residents vs non-CDI residents. Total health care costs within 2 months following the first CDI episode were also significantly higher for CDI residents ($28,621 vs $13,644, P < 0.001). CONCLUSIONS: CDI presents a serious public health issue in NHs. Mortality, health care utilization, and associated costs were significant following incident CDI episodes.

Preferences for a Clostridioides difficile vaccine among adults in the United States.

INTRODUCTION: Clostridioides difficile (C.diff) infection (CDI) causes significant morbidity and mortality among older adults. Vaccines to prevent CDI are in development; however, data on the target population's preferences are needed to inform vaccination recommendations in the United States (US). This study assessed US adults' willingness to receive a C.diff vaccine and examined how vaccine attributes influence their choices. METHODS: A cross-sectional online survey with a discrete choice experiment (DCE) was conducted among US adults aged ≥50 years. DCE attributes included effectiveness, duration of protection, reduction in symptom severity, out-of-pocket (OOP) costs, number of doses, and side effects. The DCE included 11 choice tasks, each with two hypothetical vaccine profiles and an opt-out (i.e., no vaccine). Attribute-level preference weights were estimated using hierarchical Bayesian modeling. Attribute relative importance (RI) was compared between select subgroups. RESULTS: Of 1216 adults in the analyses, 29.9% reported they knew either 'a little' (20.7%) or 'a lot' (9.2%) about C.diff before the study. A C.diff vaccine was chosen 58.0% of the time (vs. opt-out) across choice tasks. It was estimated that up to 75.0% would choose a vaccine when OOP was $0. Those who were immunocompromised/high-risk for CDI (vs. not) more frequently chose a C.diff vaccine. Decreases in OOP costs (RI = 56.1), improvements in vaccine effectiveness (RI = 17.7), and reduction in symptom severity (RI = 10.3) were most important to vaccine choice. The rank ordering of attributes by importance was consistent across subgroups. CONCLUSION: OOP cost, improvements in vaccine effectiveness, and reduction in CDI severity were highly influential to vaccine selection. Most adults aged ≥50 years were receptive to a C.diff vaccine, especially with little-to-no OOP cost, suggesting that mandating insurance coverage of vaccination with no copayment may increase uptake. The limited awareness about C.diff among adults presents an opportunity for healthcare providers to educate their patients about CDI prevention.

Excess Healthcare Costs and Resource Utilisation of Lyme Borreliosis in Germany: A Propensity Score-Matched Cohort Study.

AIM: Lyme borreliosis (LB) is the most common tick-borne disease in Germany; however, data on the economic burden of LB are limited. In this study, we aim to report healthcare costs, healthcare resource utilisation (HCRU) and diagnostic consumption associated with LB by clinical manifestation. METHOD: Using specific case definitions, patients with localised disease (erythema migrans [EM]) or disseminated disease (Lyme arthritis [LA], Lyme neuroborreliosis [LNB] and other rarer manifestations [OTH]) were identified from a claims database in 2016 and followed up for 3 years (2016-2019). After propensity score matching, excess costs and HCRU were calculated as the differences between each LB cohort and the matched control cohort. RESULTS: On a per-patient basis, the excess all-cause healthcare cost was €130 for EM during Quarter 1 of Year 1, and €1539 for LA, €3248 for LNB and €4137 for OTH during Year 1. Only for OTH, additional €1860 was observed in Year 2. No increase in costs was observed in Year 3. When extrapolated to all German patients with statutory health insurance, LB was associated with €64.5 million in excess costs. Although disseminated manifestations only accounted for 7.8% of all LB cases, they were responsible for 66% of overall costs. In addition, LB patients consumed healthcare resources of 1.4 million excess outpatient visits, 13,000 excess hospitalisations, 96,000 ELISAs and 65,000 Western blots. CONCLUSION: This study shows the substantial economic burden of LB to the German healthcare system.

Clostridioides difficile infection across the lifespan: Estimation using life tables.

Using a life tables approach with 2011-2017 claims data, we calculated lifetime risks of Clostridioides difficile infection (CDI) beginning at age 18 years. The lifetime CDI risk rates were 32% in female patients insured by Medicaid, 10% in commercially insured male patients, and almost 40% in females with end-stage renal disease.

Incidence of Lyme Borreliosis in Germany: A retrospective observational healthcare claims study.

Lyme borreliosis (LB) is the most common tick-borne disease in Germany. Although the incidence of LB in Germany has been assessed in several studies, those studies either used data from statutory surveillance, which frequently underreport cases, or data from health claims databases, which may overestimate cases due to non-specific LB case definitions. Here, using a more specific case definition, we describe the incidence of medically-attended LB by disease manifestation, age group, and federal state for the period 2015-2019. Both inpatient and outpatient cases were analyzed from a claims database. To be eligible for inclusion, patients were required to have an LB specific ICD-10 GM diagnosis code plus an antibiotic prescription, and for disseminated manifestations, a laboratory test order additionally. LB cases were classified as erythema migrans (EM), or disseminated disease including Lyme arthritis (LA), Lyme neuroborreliosis (LNB), and all other disease manifestations (OTH). Between 2015 and 2019, the incidence of medically-attended LB cases ranged from 195.7/100,000 population per year (95% confidence interval [CI], 191.0 - 200.5) to 254.5/100,000 population per year (95% CI, 249.0 - 260.0) per year. The majority of cases (92.2%) were EM, while 2.8% presented as LA, 3.8% as LNB, and 1.2% as OTH. For both EM and disseminated disease, the incidence peaked in children aged 5-9 years and in older adults. By federal state, the incidence of medically-attended EM ranged from 74.4/100,000 population per year (95% CI, 71.9 - 77.0) per year in Hamburg, to 394.1/100,000 population per year (95% CI, 370.7 - 417.6) per year in Saxony, whereas for medically-attended disseminated disease, the highest incidence was in Thuringia, Saxony, and Bavaria (range: 22.0 [95% CI, 19.9 - 24.0] to 35.7 [95% CI, 34.7 - 36.7] per 100,000 population per year). This study comprehensively estimated the incidence of all manifestations of medically-attended LB and showed a high incidence of LB throughout Germany. Results from the study support performing epidemiological studies in all federal states to measure the burden of LB and to invest in public health interventions for prevention.

Does the Vaccination against Tick-Borne Encephalitis Offer Good Value for Money for Incidence Rates below the WHO Threshold for Endemicity? A Case Study for Germany.

Tick-borne encephalitis (TBE) is a viral infection affecting the central nervous system (CNS) with potential long-term consequences including neurological sequelae. Vaccination is critical to reduce TBE morbidity and mortality, as no antiviral treatment is available. The World Health Organization (WHO) defines areas with an incidence of ≥5 cases/100,000 PPY as highly endemic and recommends that vaccination is offered to all individuals in these areas. However, access to TBE vaccination depends on recommendations and funding by national or subnational decision-makers. We assessed if TBE vaccination could offer good value for money at incidences below this threshold. METHODS: A closed-cohort Markov model was developed to estimate the cost-effectiveness of TBE vaccination. We compared primary vaccination applied to the whole population (aged above 1 year) and to a subpopulation aged between 60 and 85 years to a scenario without vaccination. Since TBE incidence is often underestimated, we included under-ascertained TBE cases and non-CNS TBE infections. Germany was used as a case study due to the availability of detailed incidence data. RESULTS: Our incidence threshold analysis showed that TBE vaccination offers good value for money well below the WHO threshold in most of the analyzed scenarios. CONCLUSIONS: Our results support a recommendation for TBE vaccination even in settings with low numbers of reported cases, especially for older patients. Furthermore, this analysis identified major research gaps regarding the costs, utilities, and clinical progression of TBE.

Increased Incidence and Risk of Septicemia and Urinary Tract Infection After Clostridioides difficile Infection.

Background: Although increased occurrence of septicemia in persons with Clostridioides difficile infection (CDI) has been reported, incidence rates and risk of septicemia and urinary tract infection (UTI) after CDI are unclear. Methods: The first episode of CDI was identified using 2011-2017 MarketScan and CMS Medicare data and CDI cases categorized by standard surveillance definitions. Uninfected persons were frequency matched 4:1 to cases by the CDI case surveillance definition. Multivariable Cox proportional hazards models were used to identify risk factors for septicemia and UTI within 90 days of CDI onset, accounting for the competing risk of death in the Medicare population. Results: The incidence of septicemia was highest after hospital-onset CDI in the Medicare, younger commercial, and younger Medicaid populations (25.5%, 15.7%, and 19.5%, respectively) and lowest in those with community-associated CDI (3.8%, 4.3%, and 8.3%, respectively). In contrast, the incidence of UTI was highest in those with other healthcare facility onset CDI in all 3 populations (32.1%, 24.2%, and 18.1%, respectively). Hospital-onset CDI was associated with highest risk of septicemia compared with uninfected controls in all 3 populations. In the younger populations, risk of septicemia was more uniform across the CDI surveillance definitions. The risk of UTI was significantly higher in all CDI surveillance categories compared to uninfected controls, and among CDI cases it was lowest in those with community-associated CDI. Conclusions: The incidence of septicemia is high after CDI, particularly after hospital-onset infection. Additional preventive measures are needed to reduce infectious complications of CDI.

Healthcare Costs of Clostridioides difficile Infection in Commercially Insured Younger Adults.

In a US adult population aged <65 years, attributable costs due to Clostridioides difficile infection (CDI) were highest in persons with hospital onset and lowest in those with community-associated CDI treated outside a hospital. The economic burden of CDI in younger adults underscores the need for additional CDI-preventive strategies.

Trends in the incidence of Clostridioides difficile infection in adults and the elderly insured by Medicaid compared to commercial insurance or Medicare only.

OBJECTIVE: Few data are available to quantify the Clostridioides difficile infection (CDI) burden in US adults depending on Medicaid insurance status; thus, we sought to contribute to this body of information. METHODS: Retrospective cohort study to identify adults with codes for CDI from 2011 to 2017 in MarketScan commercial and Medicaid databases (for those aged 25-64 years) and the CMS Medicare database (for those aged ≥65 years). CDI was categorized as healthcare-facility-associated (HCA-CDI) and community-associated CDI (CA-CDI). CDI incidence rates were compared by year, insurer, and age group. RESULTS: The overall CDI incidence in the elderly was 3.1-fold higher in persons insured by Medicare plus Medicaid than in those insured by Medicare only (1,935 vs 618 per 100,000 person years (PY)), and the CDI incidence was 2.7-fold higher in younger adults with Medicaid compared to commercial insurance (195 vs 73 per 100,000 PY). From 2011 to 2017, HCA-CDI rates declined in the younger Medicaid population (124.0 to 95.2 per 100,000 PY; P < .001) but were stable in those commercially insured (25.9 to 24.8 per 100,000 PY; P = .33). In the elderly HCA-CDI rates declined from 2011 to 2017 in the Medicare-only population (403 to 318 per 100,000 PY; P < .001) and the Medicare plus Medicaid population (1,770 to 1,163 per 100,000 PY; P < .002). Persons with chronic medical conditions and those with immunocompromising conditions insured by Medicaid had 2.8- and 2.7-fold higher CDI incidence compared to the commercially insured population, respectively. The incidence of CDI was lowest in Medicaid and commercially insured younger adults without chronic medical or immunosuppressive conditions (67.5 and 45.6 per 100,000 PY, respectively). CONCLUSIONS: Although HCA-CDI incidence decreased from 2011 to 2017 in elderly and younger adults insured by Medicaid, the burden of CDI remains much higher in low-income adults insured by Medicaid.

Epidemiology of Clostridioides difficile Infections in Germany, 2010-2019: A Review from Four Public Databases.

INTRODUCTION: Clostridioides difficile infection (CDI) is a recognized global threat especially for vulnerable populations. It is of particular concern to healthcare providers as it is found in both hospital and community settings, with severe courses, frequent recurrence, high mortality and substantial financial impact on the healthcare system. The CDI burden in Germany has been described and compared by analysing data from four different public databases. METHODS: Data on hospital burden of CDI have been extracted, compared, and discussed from four public databases for the years 2010-2019. Hospital days due to CDI were compared to established vaccine preventable diseases, such as influenza and herpes zoster, and also to CDI hospitalisations in the United States (US). RESULTS: All four databases reported comparable incidences and trends. Beginning in 2010, population-based hospitalised CDI incidence increased to a peak of > 137/100,000 in 2013. Then, incidence declined to 81/100,000 in 2019. Hospitalised patients with CDI were predominantly > 50 years of age. The population-based incidence of severe CDI was between 1.4 and 8.4/100,000 per year. Recurrence rates were between 5.9 to 6.5%. More than 1,000 CDI deaths occurred each year, with a peak of 2,666 deaths in 2015. Cumulative CDI patient days (PD) were between 204,596 and 355,466 each year, which exceeded cumulated PD for influenza and herpes zoster in most years, though year-to-year differences were observed. Finally, hospitalized CDI incidence was higher in Germany than in the US, where the disease is well recognized as a public health threat. CONCLUSIONS: All four public sources documented a decline in CDI cases since 2013, but the disease burden remains substantial and warrants continued attention as a severe public health challenge.

Incidence and burden of Staphylococcus aureus infection after orthopedic surgeries.

OBJECTIVE: To assess the 180-day incidence of Staphylococcus aureus infections following orthopedic surgeries using microbiology cultures. DESIGN: Retrospective observational epidemiology study. SETTING: National administrative hospital database. PATIENTS: Adult patients with an elective admission undergoing orthopedic surgeries in the inpatient and hospital-based outpatient settings discharged between July 1, 2010, and June 30, 2015. METHODS: Patients were identified from 181 hospitals reporting microbiology results to the Premier Healthcare Database. Orthopedic surgeries were defined using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure and current procedural terminology (CPT) codes. Microbiology cultures and ICD-9/10 diagnosis codes identified surgical site infections (SSIs), bloodstream infections (BSIs), and other infections associated postoperatively (eg, respiratory and urinary tract infections). RESULTS: Among 359,268 inpatient orthopedic surgical encounters, the S. aureus infection incidence was 1.13%: SSI, 0.68%; BSI, 0.28%; and other types, 0.17%. Among 292,011 outpatient encounters, the S. aureus incidence was 0.78%: SSI, 0.55%; BSI, 0.12%; and other types, 0.11%. Methicillin-resistant S. aureus (MRSA) infections accounted for 46% and 44% in the respective settings. Plastic/hand-limb reattachment and amputation had the highest overall S. aureus incidence in both settings. S. aureus was the most commonly isolated microorganism among culture-confirmed SSIs (48.0%) and BSIs (35.0%), followed by other Enterobacteriaceae (14.0%) for SSIs and Escherichia spp (12.5%) for BSIs. CONCLUSIONS: These findings suggest that S. aureus infections continue to be an important contributor to the burden of postoperative infections after inpatient and outpatient orthopedic procedures.

Staphylococcus aureus infections after elective pediatric surgeries.

OBJECTIVE: To determine the 180-day cumulative incidence of culture-confirmed Staphylococcus aureus infections after elective pediatric surgeries. DESIGN: Retrospective cohort study utilizing the Premier Healthcare database (PHD). SETTING: Inpatient and hospital-based outpatient elective surgical discharges. PATIENTS: Pediatric patients <18 years who underwent surgery during elective admissions between July 1, 2010, and June 30, 2015, at any of 181 PHD hospitals reporting microbiology results. METHODS: In total, 74 surgical categories were defined using ICD-9-CM and CPT procedure codes. Microbiology results and ICD-9-CM diagnosis codes defined S. aureus infection types: bloodstream infection (BSI), surgical site infection (SSI), and other types (urinary tract, respiratory, and all other). Cumulative postsurgical infection incidence was calculated as the number of infections divided by the number of discharges with qualifying elective surgeries. RESULTS: Among 11,874 inpatient surgical discharges, 180-day S. aureus infection incidence was 1.79% overall (1.00% SSI, 0.35% BSI, 0.45% other). Incidence was highest among children <2 years of age (2.76%) and lowest for those 10-17 years (1.49%). Among 50,698 outpatient surgical discharges, incidence was 0.36% overall (0.23% SSI, 0.05% BSI, 0.08% others); it was highest among children <2 years of age (0.57%) and lowest for those aged 10-17 years (0.30%). MRSA incidence was significantly higher after inpatient surgeries (0.68%) than after outpatient surgeries (0.14%; P < .0001). Overall, the median days to S. aureus infection was longer after outpatient surgery than after inpatient surgery (39 vs. 31 days; P = .0116). CONCLUSIONS: These findings illustrate the burden of postoperative S. aureus infections in the pediatric population, particularly among young children. These results underscore the need for continued infection prevention efforts and longer-term surveillance after surgery.