The Epidemiology of Clostridium difficile Infection (CDI) in Patients

with Frequent Inter-facility Transfers Reda A. Awali, MD, MPH, Vallabh Karpe, MD, Bharat Marwaha, MD, Muhammad Bilal Asghar, MD, Naveen Trehan, MD, Fatima Motiwala, MD, Amina

Pervaiz, MD, Urooj Qazi, MD, Ranbir Singh, MD, Sravya Dasyam, MD, Tejasvi Sunkara, MD and Teena Chopra, MD, MPH,

Infectious Diseases, Detroit Medical Center/ Wayne State University, Detroit, MI

ABSTRACT

Background:

Patients with frequent inter-facility transfers (IFTs) between various health care facilities including acute care hospitals, long-term acute care facilities

(LTACHs) and skilled nursing facilities (SNFs) are at increased risk of acquiring Clostridium difficile Infection (CDI).

Methods:

A prospective study was conducted between Oct 2012 and Apr 2013 on patients diagnosed with CDI using a nucleic acid amplification test (NAAT) at

a tertiary care hospital in Detroit. Medical records were reviewed for patient demographics, co-morbidities, previous hospitalizations and use of

antibiotics in the 60 days prior to CDI. Patients were then followed by monthly telephone interviews. LTACHs and SNFs, where patients were

transferred were contacted to collect information about episodes of diarrhea, use of antibiotics and recurrent CDI. Recurrent CDI was defined as

return of diarrhea and positive NAAT for CDI within 8 weeks of initial diagnosis after documented symptom resolution. Statistical analyses were

conducted using SAS version 9.3.

Results:

Mean age of the cohort (N=81) was 58 ± 20 years, 75% were African- Americans and 59% were men. Forty four patients (54%) acquired CDI after 48

hours of admission. Thirty eight patients (48%) had history of at least one prior hospitalization and prior use of 2 or more antibiotics was noted in 59

patients (73%).

The median IFTs for CDI patients was 2 (Interquartile range {IQR} = 2 – 4) while that for recurrent CDI patients was 3 (IQR = 2 – 6). Median length

of stay at the acute hospital was 9 days (IQR = 5 – 23). The median time from diagnosis to resolution of diarrhea was 17 days (IQR = 5 – 30) with

20% patients reporting persistence of diarrhea even 7 days after discharge. Twenty two patients were discharged directly to SNFs or LTACHs. Eight

patients (13%) had recurrent CDI, 2 of them being SNF residents. Factors associated with recurrences included treatment of the first episode of CDI

with metronidazole (50%) and concomitant use of antibiotics (50%). The six-month all-causes mortality was 0.5 %( n=4).

Conclusion:

With the recent implementation of the accountable care organizations and the frequent IFTs of patients, it is critical to develop standard policies for

antibiotic stewardship and infection prevention across the entire health care system.

METHODS

BACKGROUND

2

3

0

1

2

3

4

5

6

Primary CDI Recurrent CDI

Num

ber

of

inte

rfac

ilit

y tr

ansf

ers

IQR = 2-4

IQR = 2-6

CONCLUSIONS

REFERENCES

1. Johnson S. Recurrent Clostridium difficile infection: a review of risk factors, treatments, and outcomes. The Journal of infection.

2009;58:403-10.

2. Gould CV, Rothenberg R, Steinberg JP. Antibiotic resistance in long-term acute care hospitals: the perfect storm. Infection control

and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America. 2006;27:920-5.

Variable N = 81 (%)

Age (Years); Mean (S.D) 58 (20)

Race

African American

Non-Hispanic White

Others

61 (75%)

12 (15%)

8 (10%)

Gender

Male

Female

48 (59%)

33 (41%)

Hospital Acquired CDI 44 (54%)

Prior Hospitalization 38 (48%)

Prior Antibiotics 59 (73%)

Factors associated with Recurrent CDI N=8 (%)

Being an SNF resident 2 (25%)

Treatment of first episode of CDI with

Metronidazole 4 (50%)

Concomitant use of antibiotics 4 (50%)

Design: A prospective study conducted between Oct 2012 and Apr 2013 on patients diagnosed with CDI at a tertiary care hospital

in Detroit.

Measures:

• Medical records were reviewed for patient demographics, co-morbidities, previous hospitalizations and use of antibiotics in

the 60 days prior to CDI.

• Patients were followed by monthly telephone interviews and long-term care facilities were contacted to collect information

about episodes of diarrhea, use of antibiotics and recurrent CDI.

Definitions:.

• Recurrent CDI: return of diarrhea and positive NAAT for CDI within 8 weeks of initial diagnosis after documented symptom

resolution.

• Hospital acquired CDI: diagnosis of CDI more than 48 hours after hospital admission

• Patients who acquire CDI in acute care hospitals are frequently transferred to other health care facilities like long-term acute care

hospitals and skilled nursing homes; thus increasing the risk of nosocomial spread of Clostridium difficile.

• Patients admitted to long-term care facilities are also at increased risk of acquiring recurrent CDI due to their advanced age,

prolonged hospital stay and frequent use of antimicrobials (1, 2).

• Frequent inter-facility transfers is a predisposing factor for primary infections with Clostridium

difficile as well as recurrent CDI.

• Recurrent CDI is increasing in incidence. With the existing challenges in management of

recurrent CDI and frequent inter-facility transfers of patients, it is critical to develop standard

policies for antibiotic stewardship and infection prevention across the entire health care system.

RESULTS

TABLE 1. Characteristics of CDI patients

TABLE 2. Factors associated with recurrent CDIs FIGURE 1. Inter-facility transfers in patients with primary and recurrent CDI

TABLE 3. Outcomes of CDI patients

1402

Outcome Variable Median [IQR]

Length of hospital stay 9 [5 – 23]

Time from diagnosis to resolution of diarrhea 17 [5 – 30]

6-months all-causes mortality; n (%) 4 (0.5%)

ACKNOWLEDGMENTS

We would like to thank OPTIMER PHARMACEUTICALS for funding our study

University Health Center

4201 St. Antoine, Suite 2B

Detroit, MI 48201

rawali@med.wayne.edu