Flaw-ridden testing for dangerous infections vexes health officials

Clostridium difficile is a dangerous, health care associated infection that can cause severe diarrhea, abdominal pain, even death. Here, spores surround a long difficile bacterium. (Scimat/Photo Researchers, Inc Copyright © 2012)

Clostridium difficile is a dangerous, health care associated infection that can cause severe diarrhea, abdominal pain, even death. Here, spores surround a long difficile bacterium. (Scimat/Photo Researchers, Inc Copyright © 2012)

This story originally appeared in the Stockton Record.

The thick new state report about infections at California’s hospitals revealed what looked like alarming numbers for San Joaquin County.

Two of its hospitals appeared to rank among the state’s worst for a deadly kind of intestinal infection that can spread via invisible spores in hospitals, nursing homes and doctors’ offices, killing an estimated 14,000 to 30,000 people a year nationwide.

So why were more patients at Dameron Hospital and Lodi Memorial Hospital seemingly getting sick in 2010 and early 2011 with Clostridium difficile, an infection marked by severe diarrhea, and, in some cases, ravaged colons and death?

The reality is not so simple. The two hospitals use a more modern, sensitive test than most medical centers to check if their patients have C.difficile. Those lower rates at other hospitals may reflect the use of older kinds of tests.

A two-month Record investigation has found that current state and federal tools to diagnose and track C. difficile patients are riddled with flaws. Not only are testing methods in question, but many cases go uncounted.

To fight the spread of C. difficile, health experts say they must be able to count and track infected patients. That’s a challenge they haven’t solved.

For instance, infection counts may increase dramatically across the country, experts say, when more medical centers embrace the new, sensitive tests.

“We may find 30 percent, 40 percent, 50 percent more. There could even be a doubling of cases,” said Dr. Cliff McDonald, a leading C. difficile expert at the U.S. Centers for Disease Control and Prevention in Atlanta.

Federal health officials are so concerned that they have rushed to finish a formula, to be unveiled this week, that will adjust for the variation.

In San Joaquin County, seven hospitals reported 377 cases of C. difficile during the 12 months ending in March 2011, according to a state report published in January by the California Department of Public Health.

State officials have held back the public release of the latest statewide hospital C. difficile counts, concerned about a hodgepodge of testing methods. A new report will be published later this fall, a spokesman wrote in an email.

So Stockton area residents are in the dark, with no way to know whether C. difficile is a serious health problem in their community.

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C. difficile, once an obscure infection, has ballooned in the United States in the past decade, now sickening nearly a half-million people each year and racking up $8 billion in medical bills.

Hospitals, patients and their families face a gargantuan task as they wrestle to control a dangerous pathogen that has outstripped even invasive MRSA, or methicillin-resistant Staphylococcus Aureus, the best-known healthcare-associated infection.

“As a pathogen, C. diff is right up there. If it’s not No. 1, it’s No. 2,” McDonald said.

Its growth places in stark relief a perplexing reality of 21st century medicine: Patients are being infected in the very hospitals that are charged with healing them.

Lisa McGiffert, director of Consumer Union’s Safe Patient Project, says “C. diff is like Ground Zero,” she said.

Each year, Stockton colon surgeon Dr. Peter Tuxen treats two or three C. difficile patients with colons so damaged that he must remove the infected areas to save the patients’ lives.

“When it comes to infection, you would think, after 50 years of antibiotics and 100 years of listeria, we would have solved it. We haven’t,” Tuxen said.

Nor have experts solved the mish-mash of tests. Without a standard measure, hospitals cannot accurately compare their C. difficile problem with other hospitals. And they may be missing cases.

In San Joaquin County, the seven general acute-care hospitals use at least three different C. difficile tests. Dameron and Lodi Memorial were the first to adopt the newer, more expensive method called PCR—for polymerase chain reaction—and St. Joseph’s Medical Center and San Joaquin General Hospital followed last year.

The Kaiser Permanente hospital in Manteca turns to PCR to confirm C. difficile in patients who have already tested positive with another test.

Kaiser uses electronic records that can pick up C. difficile cases, not only in its hospitals, but in its clinics and doctors’ offices.

But most hospitals aren’t part of such networks, and many cases diagnosed at doctors’ offices, surgery clinics and nursing homes can fall through the reporting cracks.

CDC experts estimate that three-quarters of all C. difficile cases occur outside hospitals. Yet in California and most other states, hospitals are the only health facilities required to count them.

“I think it is enormously under-reported,” said Christian John Lillis, co-founder and director of the Peggy Lillis Memorial Foundation, named for his mother, who died of the infection. The New-York-based nonprofit is devoted to C. difficile education and solutions.

C. difficile last year killed more Americans than HIV/AIDS and drunken driving combined, Lillis said. “But the data isn’t even being gathered for us to understand what is to me a public health crisis.”

Under California public health laws, for example, the infection is overshadowed by other communicable illnesses.

The state does not list it as a “reportable disease,” a list that now includes tuberculosis, pertussis, certain MRSA cases and 81 other infectious diseases. That means local doctors are not required to report cases to Public Health Services of San Joaquin County.

In fact, the county’s public health officer, Dr. Karen Furst, doesn’t oversee C. difficile at all.

“I don’t get involved in that area,” Furst said. “The reality is that we don’t deal with C. difficile here. It’s not reportable.”

That onus falls on the state health department, which monitors infectious diseases and health care quality. In recent years, it has stepped up its oversight of health care associated infections.

Today, it is charged with carrying out a 2008 law requiring nearly 400 hospitals to inform the state about their rates of infection for C. difficile, MRSA and four other types of healthcare-acquired infections.

To date, state officials have produced three reports using those numbers, most recently in August. But C. difficile rates were missing.

State officials initially said they were waiting for CDC to release its new formula to correct the problems caused by the different testing methods. CDC is expected to announce that formula at a major infection conference that begins Wednesday in San Diego.

Now, state officials say they will go ahead and release unadjusted C. difficile infection rates this fall. A report using the new CDC formula will not come out until next year.

To date, state reports suggest that cases surged in San Joaquin County in the year ending March 2011.

Area hospitals reported 377 cases during those 12 months. That’s a jump from the 240 cases reported in the 15 months ending in March 2010.

But testing and reporting methods have changed since 2009, obscuring whether the number of cases here – and in the rest of the state -- is rising or falling.

The state’s delay in releasing new C. difficile data has made some patient advocates suspicious. They include Carole Moss, the Riverside County resident who spearheaded the 2008 reporting law after her 15-year-old son died of MRSA. Moss wonders if state officials are sitting on numbers showing that C. difficile cases in California are on the increase.

A panel of hospital infection experts and others has advised the department on its infection reporting.

The panel’s subcommittee on C. difficile is “currently on hiatus,” according to the state’s website. In an email, state spokesman Ralph Montano said that after the state’s first public report on C. difficile rates, “There has not been a need for a subcommittee to be reactivated.”

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Authors

Deborah Schoch

Senior writer Deborah Schoch reports on hospitals and health care delivery, nursing homes, environmental health and food. Her most recent articles have examined patient safety andhospital infections. She was a founding writer with the Center’s pilot project. Schoch spent 18 years as a staff writer at the Los Angeles Times, covering public health and the environment. She was a member of the Times newsroom teams that won Pulitzer Prizes for breaking news in 1992 and 1994. Schoch graduated from Cornell University and was a Nieman Fellow at Harvard University in 1999-2000, studying science, law and policy. Her work at the Center has won several honors, including first place in the 2010 Awards for Excellence in Health Care Journalism, from the Association of Health Care Journalists. She sits on the AHCJ board’s Right-to-Know Committee, which works to improve access to public health records.

© 2014 California Healthcare Foundation Center for Health Reporting

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