Incidence and Impact of Clostridium difficile Associated Diarrhea in Long-term Care

Background:    Clostridium difficile associated diarrhea (CDAD) causes significant morbidity and mortality in the elderly.  There is little data on the impact of CDAD in residents of long-term care facilities.

Objective: To assess the incidence and outcome of (CDAD) in a long-term care facility.

Methods: We conducted a retrospective cohort study in a 262-bed long-term care  VA facility in Pittsburgh, PA for the period January 2004 through June 2010.   CDAD  was identified by positive stool C. difficile toxin assay and acute diarrhea.   Patients were categorized into two groups, hospital-associated CDAD (HACD) or long-term care facility-associated CDAD (LACD) and followed for 6 months. 

Results: The annual rate of CDAD varied between 0.15 and 0.47 per 1000 patient days.  We identified 162 patients, 96 patients (59.3%) with HACD and  66 patients (40.7%) with LACD.  Median age was 74 years and 77 years, respectively for HACD and LACD, P=0.055. There were more patients with at least one relapse of C. difficile infection during 6 months of follow-up in LACD (32/66, 48.5%) than in HACD (28/96, 29.2%), P=0.009. Logistic regression analysis showed that Age >=75 years (OR=2.331, 95% CI 1.073 – 5.065, P=0.033), >2 transfers to acute care hospital (OR=7.877, 95% CI 1.883 – 32.949, P=0.005), and LACD (OR=3.151, 95% CI 1.409 – 7.047, P=0.005) were associated with relapse of CDAD.  Cox regression analysis showed that presence of a feeding tube (OR=3.055, 95% CI 1.042 – 8.958, P=0.042) was associated with mortality of CDAD infection in a long-term care facility .

Conclusions: The majority of CDAD infection in our long term facility was acquired during an acute care hospitalization.  However, 40% of cases were acquired within the long term care facility indicating a substantial degree of transmission.   The long-term care setting presents unique challenges in prevention of infection; optimal strategies to prevent CDAD are needed.