infection (CDI) is a potentially deadly1
and undeniably serious health concern in the United States.2,3
Older adults (≥65 years of age) are particularly vulnerable to this infection,1
as its two main risk factors are exposure to antibiotics and health care settings such as acute care hospitals (AHs) and long-term care facilities (LTCFs).4
Additionally, the incidence of CDI is five to ten-fold greater in older adults as compared with younger adults,3
and they are at a significantly higher risk for severe and complicated disease as well.5
Our ageing society, coupled with recent changes in hospital reimbursements, has resulted in a shift away from patient care at AHs and towards LTCFs.6,7
As a consequence, an important avenue for CDI transmission has emerged from this interfacility movement,8,9
Because preventing CDI transmission over the continuum of care between AHs and LTCFs represents a growing challenge for infection control and prevention,10
additional studies on this subject are required.
The results of one study addressing this timely topic were published recently in the American Journal of Infection Control
According to lead author Reda A. Awali, MD, MPH, from the division of infectious diseases at the Detroit Medical Center and Wayne State University in Detroit, Michigan, and her colleagues, this particular study was conducted in order to, "... better understand the epidemiology of CDI and the role of interfacility sharing practices in spreading CDI across the continuum of care." The investigators also explained the goals of the study by stating, "The aim of the current study was to investigate risk factors associated with interfacility transfers (IFTs) among CDI patients and compare the clinical outcomes of CDI patients with and without IFTs."
To accomplish their study aims, Awali et al. conducted a prospective case-control study on patients admitted to their tertiary care hospital with a diagnosis of CDI between August 2012 and September 2013. Additionally, patients were followed-up for one year. Those admitted from other health care facilities and discharged to LTCFs served as the cases, while the controls were patients admitted from- and discharged back to their homes.
Of the 143 patients included in the study, 36 (30%) were IFT cases and 84 (70%) were controls. Roughly one-third (34%) of the entire study population was discharged directly to LTCFs.
In the battery of study results reported, several showed statistically significant between-group differences. For example, statistically significant independent risk factors for cases as compared to controls as determined by multivariate analyses included a Charlson Comorbidity Index score ≥6 and hospital-acquired CDI after controlling for confounding effects attributable to gastrointestinal endoscopic procedures, prior use of laxatives, ≥7 antibiotic days prior to CDI, and a ≥0.3 mg/dL difference between the highest and baseline creatinine. Perhaps not surprisingly, cases showed a greater likelihood of readmission to an AH within 90 days of discharge, a longer median length of stay, and a significantly higher one-year mortality rate as compared with controls.
In describing one of their more significant findings, the investigators stated, "... most of our IFT patients were discharged to LTCFs before completing or within 1 month of completing their CDI treatment." This strongly suggests that these patients could have been reservoirs for C. diff
at the time of IFT, representing a real and present danger for spreading CDI to their new environments.
Regarding the broader implications of their findings, Dr. Awali and colleagues suggested, "... introducing CDI surveillance and establishing an organized interfacility disclosure system ..." They also noted the need for, "... collaboration between acute care and LTCFs to advance infection control measures and optimize the use of antimicrobials."
Ultimately, the results presented in the report begin an elucidation of the complexity of IFTs and highlight their potential role in the spreading of CDI throughout the health care system in general.
William Perlman, PhD, CMPP is a former research scientist currently working as a medical/scientific content development specialist. He earned his BA in Psychology from Johns Hopkins University, his PhD in Neuroscience at UCLA, and completed three years of postdoctoral fellowship in the Neuropathology Section of the Clinical Brain Disorders Branch of the National Institute of Mental Health.
- Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372:825–34.
- Ricciardi R, Rothenberger DA, Madoff RD, Baxter NN. Increasing prevalence and severity of Clostridium difficile colitis in hospitalized patients in the United States. Arch Surg 2007;142:624–31, discussion 631.
- McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis 2006;12:409–15.
- Blossom DB, McDonald LC. The challenges posed by reemerging Clostridium difficile infection. Clin Infect Dis 2007;45:222–7.
- Gravel D, Miller M, Simor A, Taylor G, Gardam M, McGeer A, et al. Health care-associated Clostridium difficile infection in adults admitted to acute care hospitals in Canada: a Canadian Nosocomial Infection Surveillance Program Study. Clin Infect Dis 2009;48:568–76.
- Kossovsky MP, Sarasin FP, Chopard P, et al. Relationship between hospital length of stay and quality of care in patients with congestive heart failure. Qual Saf Health Care 2002;11:219–23.
- Clarke A. Length of in-hospital stay and its relationship to quality of care. Qual Saf Health Care 2002;11:209–10.
- Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. Vital Health Stat 13 2009;1–155.
- Bootsma MC, Diekmann O, Bonten MJ. Controlling methicillin-resistant Staphylococcus aureus: quantifying the effects of interventions and rapid diagnostic testing. Proc Natl Acad Sci USA 2006;103:5620–5.
- Huang SS, Avery TR, Song Y, et al. Quantifying interhospital patient sharing as a mechanism for infectious disease spread. Infect Control Hosp Epidemiol 2010;31:1160–9.
- Awali RA, Kandipalli D, Pervaiz A, Narukonda S, Qazi U, Trehan N, Chopra T. Risk factors associated with interfacility transfers among patients with Clostridium difficile infection. Am J Infect Control. 2016 May 17. pii: S0196-6553(16)30177-8. doi: 10.1016/j.ajic.2016.03.037. [Epub ahead of print].
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