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Point-Prevalence of Healthcare-Associated Infection in China in 2010: A Large Multicenter Epidemiological Survey

for the testing was not always clearly stated, the majority of these tests seemed to be tests of cure. The greatest discordance between the clinical definition and the surveillance definition was among residents admitted to the LTCF who had already received a diagnosis of and therapy for CDI. Of 25 cases, 18 (72%) were undetected by the surveillance definition. Testing obtained at the LTCF for some of these residents who were already known to have CDI detected the remaining 7 cases (28%) with the surveillance definition. Table 1 shows additional details regarding the discrepancies between the clinical and surveillance definitions of CDI. In a single VA LTCF, the NHSN surveillance definition, based on nonduplicative testing, underestimated the clinical incidence of CDI by approximately 25%. The surveillance definition successfully captured CDI cases involving residents with disease onset and treatment at the LTCF. The most notable inaccuracy for the surveillance definition is that it did not reliably account for CDI in residents who were admitted to the LTCF who were already receiving therapy, thus underestimating the incidence of disease. Modifying the surveillance definition to include residents admitted to the LTCF who are receiving therapy for CDI may offer a practical strategy to reduce this discrepancy. Additional inaccuracies stemmed from inappropriately ordered C. difficile testing. Testing ordered for LTCF residents already receiving treatment for known CDI led to overestimates of disease incidence; addressing this involves provider education. Testing ordered for residents with recurrent CDI or for those ultimately determined to be asymptomatic carriers with diarrhea due to other causes accounted for less than 10% of the discrepancies between the clinical and surveillance definitions. Similarly, residents with CDI who were transferred to acute care before being tested and were thus missed by the surveillance definition accounted for just 4% of cases. To our knowledge, this is the first comparison of the incidence of CDI using the NHSN surveillance definition with the clinically defined disease CDI among LTCF residents. Our study has some limitations. It is based on a retrospective cohort of residents from a single VA LTCF. Both the closed system (ie, most residents come from the affiliated VA hospital), the predominantly male population, and the providers’ practice patterns may limit applicability of our findings to other LTCFs. Our findings suggest that including residents admitted to the LTCF with known CDI in the surveillance definition may improve the accuracy of the definition.