Quantifying the contributions of asymptomatic and symptomatic colonized patients to Clostridioides difficile acquisition in oncological units

Abstract Objective Leukemic and hematopoietic cell transplant patients have one of the highest incidences of C. difficile infection (CDI). While CDI patients are considered the primary source of transmission, asymptomatic colonized patients (AC) can progress to CDI or contribute to in-unit transmission. We aim to quantify the roles of CDI and AC patients in C. difficile importation and transmission within oncological units. Design Prospective cohort study Setting Two leukemia and HCT transplant units in a large tertiary care hospital in the US Methods We developed a stochastic, individual-based network model to simulate C. difficile acquisition and transmission. Data from cultures and nucleic acid amplification testing (NAAT) obtained at admission and weekly, and toxin enzyme immunoassay (EIA) tests used for CDI diagnosis were used to calibrate the model. Healthcare worker room assignments informed the network structure. Key parameters were estimated via particle filtering. Results The model reproduced observed weekly test counts and transmission pairs. AC patients were the primary source of new colonizations: 51% were due to importation (of those, 88% were admitted as AC), and 49% were due to transmission (AC was the source in 92% of transmissions). Sensitivity analysis showed that these findings were most influenced by the colonization rate and rates of environmental contamination and cleaning. Conclusions These findings reinforce the role of AC, particularly via admission importation, in sustaining C. difficile transmission in high-risk hospital settings. Infection control focused on CDI effectively reduced onward transmission, as indicated by CDI’s low contribution to new colonizations.