Lower socioeconomic status linked to community-associated C. difficile
Communities with lower socioeconomic status have a higher incidence of community-associated Clostridioides difficile infection, according to study results published in Clinical Infectious Diseases.
In what researchers called the largest analysis to date examining the association between communities’ socioeconomic status (SES) and community-associated CDI (CA-CDI) prevalence, the link was “specifically [present in] neighborhoods that have households with low income or that are receiving public assistance income, or residents living below the poverty level, who are unemployed, or who have public health insurance. Additionally, communities with people who are foreign-born or speak less English at home or with crowding in homes have a higher CA-CDI incidence.”
“In recent years, CDI has been increasingly reported in the community setting in healthier populations previously thought to be low-risk,” Kimberly Skrobarcek, MD, a medical officer in the CDC’s Division of Global Migration and Quarantine, told Healio. “Up to 20% of those diagnosed with CA-CDI have no history of recent antibiotic or outpatient health care exposures, which are considered traditional risk factors for CDI.”
“Additionally,” Skrobarcek said, “even though it is widely accepted that SES plays a significant role in acquisition and outcome for many infectious diseases, limited data exist regarding the SES factors that might influence the emergence and spread of CDI in the community. Therefore, we conducted this analysis to identify community-level SES variables that are associated with CA-CDI incidence.”
Skrobarcek and colleagues assessed data collected by the CDC’s Emerging Infections Program, which conducts CDI surveillance in 35 counties in 10 states. According to the study, there were 9,682 CA-CDI cases identified in these areas during 2014-2015, of which 9,413 (97.2%) were included in the analysis.
According to the study, an analysis “identified a three-factor model that accounted for 95% of the observed variance.” They referred to the SES variables as “poverty,” “foreign born” and “high income.”
Using a multivariate analysis, Skrobaracek and colleagues determined that “poverty” (RR = 1.19; 95% CI, 1.15-1.22) and “foreign born” (RR = 1.05; CI, 1.02-1.08) were significantly associated with high CA-CDI incidence, whereas “high income” was significantly associated with low CA-CDI incidence (RR = 0.95; CI, 0.92-0.97).
According to Skrobarcek, there are many different components of SES that could lead to an increased risk for CA-CDI.
“We believe that living in an impoverished community could be a proxy for the type of outpatient health care exposures that increase one’s risk of developing CA-CDI,” she said, adding that individuals who are uninsured, or underinsured may be more likely to visit EDs a high-risk health care setting or that household crowding can lead to an increased risk for developing CDI, and that foreign-born populations and those who speak less English at home may not have adequate health education resources available in their preferred language, leading to an inadequate understanding of the risks associated with antibiotic use.
“This was only the first step to identify the types of communities where CA-CDI is emerging,” Skrobarcek said. “Future studies are needed to determine whether this association is due to the effect of an individual being impoverished, an individual living in an impoverished area, or a combination of both effects. Understanding the mechanisms by which SES factors impact CA-CDI incidence could help guide prevention efforts in these higher risk areas.”