Jim Kling

October 23, 2012

LAS VEGAS, Nevada — A new study suggests that Clostridium difficile infections are more likely to be acquired from long-term care facilities (LTCFs) or the community rather than in hospitals. The work was presented here at the American College of Gastroenterology (ACG) 2012 Annual Scientific Meeting and Postgraduate Course.

Most epidemiological studies on Clostridium difficile–associated diarrhea (CDAD) have looked at hospitalized patients who acquired the infection in the hospital. However, CDAD-infected patients are increasingly being admitted to hospitals from LTCFs.

To study the epidemiology of CDAD, the researchers conducted a retrospective analysis of all patients diagnosed with CDAD who were admitted to an acute-care hospital between January 2005 and December 2010. Patients (n = 258) were only classified as having CDAD if they showed clinical symptoms and tested positive in a C. difficile stool toxin assay.

They classified the patients into 3 groups: hospital-acquired, long-term care facility–acquired (LTCF), and community-acquired. Only 53 (20.6%) patients were classified as hospital-acquired, compared with 119 (46.1%) from LTCFs and 86 (33.3%) from the community. Patients in the LTCF population had a higher mean age than the other groups (P < .0001).

The researchers also classified patients as having diarrhea or nondiarrhea symptoms, including fever, abdominal pain, and altered mental status. Eighteen of 119 patients in LTCF had acute diarrhea, compared with 25 of 86 with community-acquired infections (P = .0248). The majority (80 of 119) of LTCF patients presented with nondiarrheal symptoms.

LTCF patients were most likely to be currently treated with proton pump inhibitors (PPIs) (73%), followed by patients with hospital-acquired CDAD (69.8%) and community patients (43%; P =.0012). For 24.13% of LTCF patients on PPIs, the researchers could find no appropriate indication for their use. This was true in 12.9% of patients with hospital-acquired infections and 32.1% of those with community-acquired infections.

The results suggest an epidemiological shift in CDAD from a hospital-acquired infection to community- and LTCF-associated infections.

Experts Explain Reasons for the Shift

"Usually people link C. difficile infection with diarrhea as the main presenting symptom, but that wasn't the main complaint (of those coming from LTCRs)," Shashank Garg, MBBS, a resident in internal medicine at Sinai Hospital of Baltimore, Maryland, who presented the research, told Medscape Medical News.

Patients who present with unexplained fever, abdominal pain, or altered mental status should be checked for C. difficile infection, according to Dr. Garg.

The overall incidence of C. difficile infection has not changed much, but this study suggests that it is becoming more common in LTCRs and less common in hospitals. "That may very well be because there have been better infection-control efforts put in place over the last several years in the acute care facilities. Another reason is that skilled nursing communities are a hotbed of potential infections because you have chronically ill people in an environment where infection control measures are hard to put in place," Mark Mellow, MD, medical director of INTEGRIS Digestive Health Center, told Medscape Medical News.

PPI overuse is also an important factor. "It's correlated with C. diff infection. [The researchers] could not find a legitimate cause for their use in a sizeable number of patients. There [is] a mistaken sense that people need to be on ulcer protection because they [a]re sick, when that [is] really not true. Another problem is that many times, the primary care provider is not intimately involved with the patient's care when they are in a hospital or a skilled nursing facility. So it is very hard for that doctor to intervene and say this patient should no longer be on [a PPI]," added Dr. Mellow.

Dr. Garg and Dr. Mellow have disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2012 Annual Scientific Meeting and Postgraduate Course. Abstract P857. Presented October 22, 2012.