Abbreviated version of the CDC's Sept 16 COCA conference call. I am also uploading an even shorter version. Check out the document to see the web address of the original.

1. This is an abbreviated version of the PowerPoint presentation that accompanied the CDC's Sept 16, 2008 COCA Conference Call. For the full presentation, visit http://www.emergency.cdc.gov/coca/callinfo.asp (This version should not be used as a basis for making decisions about diagnosis or infection control.)‏

2. Changing Epidemiology and Prevention of Clostridium difficile Carolyn Gould, MD, MS Division of Healthcare Quality Promotion Clinician Outreach and Communication Activity September 16, 2008 The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention No Conflicts of Interest to Disclose

7. How important are asymptomatic carriers in transmission? Riggs MM et al. Clin Infect Dis 2007; 45:992–8

8. Rationale to consider extending isolation beyond duration of diarrhea Bobulsky GS et al. Clin Infect Dis 2008; 46:447–50

9. Environmental control: Effect of hypochlorite in highly endemic ward Mayfield JL. Clin Infect Dis 2000;31:995–1000

10. Novel Risk Factors, Washington University Prevention Epicenter (n=36,086)‏ CI=confidence interval; IV=intravenous; OR=odds ratio. Dubberke ER, et al. Clin Infect Dis. 2007;45:1543-1549. 0.5 (0.3–0.6)‏ Metronidazole 1.9 (1.3–2.7)‏ IV vancomycin, >7 days 2.5 (1.8–3.5)‏ Fluoroquinolones, >7 days 1.6 (1.3–2.1)‏ Proton pump inhibitors 2.0 (1.6–2.5)‏ Histamine-2 blockers Medications 4.0 (2.9–5.6)‏ >1.4 2.9 (2.1–4.2)‏ 0.3–1.4 Reference <0.03 C. difficile -associated disease pressure OR (95% CI)‏ Risk Factor by Multivariable Analysis

11. Quinolone Restriction Period Nimber of Defined Daily Doses 2005 2006 2007 Month and Year Impact that Restricting Fluoroquinolones can Have on Reducing Unnecessary Antimicrobial Use 0 500 1000 1500 2000 2500 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Aminoglycosides Cephalosporins (1st gen.)‏ Cephalosporins (2nd gen.)‏ Cephalosporins (3rd and 4th gen.)‏ Quinolones Vancomycin Piperacillin/Tazobactam Ampicillin/Sulbactam Azithromycin Carbapenems Aztreonam Clindamycin Kallen, et al. 18th Annual Meeting of The Society for Healthcare Epidemiology of America (SHEA), April 6, 2008; Orlando, FL.

12. Desperate Measures for Desperate Times: Restricting all Fluoroquinolones to End an Outbreak Kallen, et al. 18th Annual Meeting of The Society for Healthcare Epidemiology of America (SHEA), April 6, 2008; Orlando, FL. Number of Cases Month and Year Beginning of outbreak period Quinolone restriction New housekeeping company Quinolone restriction partially lifted 2004 2005 2006 2007

15. Recommendations for Surveillance of Clostridium difficile Infection Admission Discharge < 4 weeks 4-12 weeks HO-HCFA CO-HCFA Indeterminate CA-CDI Time 48 h > 12 weeks * HO: Hospital (Healthcare) onset CO-HA: Community Onset Healthcare-associated CA: Community Associated * Depending upon whether patient was discharged within previous 4 weeks, CO-HA vs. CA CDAD Surveillance Working Group. Infect Control Hosp Epidemiol 2007; 28:140-145

16. Clostridium difficile Infection (CDI) cases N = 1046 Healthcare facility–onset Healthcare facility-associated (HO-HCFA)‏ N=584 (56%)‏ (Including 142 with onset in another HCF)‏ Community Onset **Excluded: Prisoner: 8 Out of State:20 Bone Marrow Transplant: 17 Hemodialysis:29 Community Onset Healthcare facility-associated (CO-HCFA ) Indeterminate Community Associated (CA) N= 462 (44%)‏ 40 (4%)‏ 94 (9%)‏ 208 (20%)‏ Unknown Excluded** 46 (4%)‏ 74 (7%)‏ Adapted from Kutty PK, et al. Infect Control Hosp Epidemiol. 2007;29:197-202.

18. Human CDAD Caused by Strains Similar to Animal Epidemic Strains, 2001–2006 Jhung MA, et al. Second International Clostridium difficile Symposium, June 6-9, 2007; Maribor, Slovenia. Source Binary toxin Toxino type tcdC deletion Human Human Human Pig Pig Pig Pig Pig Pig Pig Pig Human Human Human Human Hosp Env V V V V V V V V V V V V V V V V + + + + + + + + + + + + + + + + + 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp 39 bp