Detection and Infection Prevention Differs between Community Onset (CO) and Hospital Onset (HO) Clostridium difficile Cases

Background: Clostridium difficileassociated diarrhea (CDAD) remains a problem in hospitals nationwide, including Veterans Affairs (VA) hospitals. Cases are classified as either community onset (CO) or hospital onset (HO). CO cases contribute a substantial portion of the total CDAD burden in the state of North Carolina (58% in 2005) and at our facility (34-35%). Recent surveillance at our facility suggests that despite their frequency, few hospital outbreak clusters originate from CO cases. Accordingly, we performed a retrospective chart review of acute care inpatients to determine if there are differences in identifying and initiating precautions between CO and HO cases.

Methods: CDAD patients were identified during prospective surveillance over the past 3 fiscal years (Oct. 2012-Sept. 2015). CO or HO CDAD cases were determined according to CDC definitions. We analyzed based on: 1) the number of hospital days between the onset of diarrhea and stool PCR test order (cases that had same day testing were designated 0 days and days of diarrhea in the community were excluded for CO cases) and 2) if enteric precautions (contact precautions plus use of soap and water) were initiated when diarrhea was discovered (i.e. prior to test results). We collected demographic and clinical information on all patients. Statistical comparisons were made with Fisher’s exact test.

Results: Of the 268 CDAD patients identified over the 3 years, 117 (43.6%) were CO cases and 151 (56.3%) were HO cases. For time-to-testing, 62 CO cases (53.0%) vs. 66 HO cases (43.7%) were tested on the same day as diarrhea onset; 44 CO cases (37.6%) vs 42 HO cases (27.8%) after 1 day; 9 CO cases (7.7%) vs 19 HO cases (12.6%) after 2 days; and 2 CO cases (1.7%) vs 24 HO cases (15.9%) after 3 days or more (p <.0001). For the enteric precautions, 53 CO cases (45.3%) and 31 HO cases (20.5%) were placed on precautions when diarrhea was first discovered (p<.0001).

Conclusion: CO-CDAD cases were more likely to be tested early and have empiric precautions initiated on the day of diarrhea onset than HO cases. Delays in suspecting infectious diarrhea and difficulty with bed reassignment are potential reasons for these results. Measures should be taken to increase the use of empiric isolation and the speed of identification.