Infection Control & Hospital Epidemiology (2018), 39, 909–916 doi:10.1017/ice.2018.106
Original Article
Transmission of Clostridium difficile from asymptomatically colonized or infected long-term care facility residents
Curtis J. Donskey MD1, Venkata C. K. Sunkesula MD2, Nimalie D. Stone MD3, Carolyn V. Gould MD3, L. Clifford McDonald MD3, Matthew Samore MD4, JeanMarie Mayer MD5, Susan M. Pacheco MD5, Annette L. Jencson CIC2, Susan P. Sambol BS5, Laurica A. Petrella BS6, Christopher A. Gulvik PhD3
and Dale N. Gerding6,7 1Geriatric Research Education and Clinical Center, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, 2Research Service, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, 3Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion, Atlanta, Georgia, 4University of Utah School of Medicine, Division of Epidemiology, Salt Lake City, Utah, 5University of Utah School of Medicine, Salt Lake City, Utah, 6Edward Hines, Jr Veterans Affairs Hospital, Hines, Illinois and 7Loyola University, Chicago Stritch School of Medicine, Maywood, Illinois
Abstract
Objective: To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions. Design: A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS). Setting: Veterans Affairs hospital and affiliated LTCF. Participants: The study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases. Results: Of the 37 CDI cases, 7 (18.9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11.5%) and 4 of 11 LTCF-associated cases (36.4%). Of the 7 transmissions linked to LTCF residents, 5 (71.4%) were linked to asymptomatic carriers versus 2 (28.6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases. Conclusions: Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.
(Received 3 February 2018; accepted 12 April 2018; electronically published May 31, 2018)
During the past 15 years, the incidence of Clostridium difficile infection (CDI) has increased dramatically in association with emergence of the BI/NAP1/027 epidemic strain.1 The increase in CDI incidence has occurred in all age groups, but the elderly have been disproportionately affected, and long-term care facilities (LTCFs) have borne a significant proportion of the increasing burden of CDI.2–4 In a recent national surveillance study, an estimated 36% of healthcare-facility–associated CDI cases in the United States had their onset in LTCFs versus 37% in hospitals.1 Moreover, many patients diagnosed with CDI in hospitals are discharged to LTCFs.5 Asymptomatic carriage of toxigenic C. difficile is common among LTCF residents.6,7 In an outbreak
Author for correspondence: Curtis J. Donskey, MD, Geriatric Research Education
and Clinical Center, Louis Stokes Veterans Affairs Medical Center, 10701 East Blvd., Cleveland, OH, 44106. E-mail:
Curtis.Donskey@
va.gov Cite this article: Donskey CJ, et al. (2018). Transmission of Clostridium difficile from
asymptomatically colonized or infected long-term care facility residents. Infection Control & Hospital Epidemiology 2018, 39, 909–916. doi: 10.1017/ice.2018.106
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
setting in a LTCF, residents with asymptomatic carriage out- numbered those with CDI by a factor of 7 to 1.6 Despite evidence that CDI and asymptomatic carriage of C. dif-
ficile are common in LTCFs, current infection control strategies for CDI focus primarily on the acute-care setting for several reasons.8 First, control measures for CDI, including contact precautions and enhanced environmental cleaning, may be viewed as contrary to the goal of providing a home-like environment for LTCF residents. Second, LTCFs have relatively few resources to devote to infection prevention and limited access to infection control expertise.9 Third, many LTCF-associated CDI cases occur within 1 month after hospital discharge, suggesting acquisition of C. difficile in the hospi- tal.2–4,10,11 Finally, although evidence that asymptomatic carriers may contribute to transmission in hospitals is mounting,12–14 it has not been demonstrated that LTCF residents with asymptomatic carriage are an important source of transmission. In previous studies, we demonstrated that asymptomatic car- riage of toxigenic C. difficile is common in the LTCF affiliated with
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