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Outpatient healthcare settings and transmission of Clostridium difficile.

Jury LA, Sitzlar B, Kundrapu S, Cadnum JL, Summers KM, Muganda CP, Deshpande A, Sethi AK, Donskey CJ - PLoS ONE (2013)

Bottom Line: For 33 community-associated CDI cases, 31 (94%) had an outpatient visit during the 12 weeks prior to onset of diarrhea.Patients with recent CDI present a significant risk for transmission of spores during outpatient visits.The outpatient setting may be an underappreciated source of community-associated CDI cases.

View Article: PubMed Central - PubMed

Affiliation: Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America.

ABSTRACT

Background: Recent reports suggest that community-associated Clostridium difficile infection (CDI) (i.e., no healthcare facility admission within 90 days) may be increasing in frequency. We hypothesized that outpatient clinics could be an important source for acquisition of community-associated CDI.

Methods: We performed a 6-month prospective study of CDI patients to determine frequency of and risk factors for skin and environmental shedding during outpatient visits and to derive a prediction rule for positive cultures. We performed a point-prevalence culture survey to assess the frequency of C. difficile contamination in outpatient settings and evaluated the frequency of prior outpatient visits in patients with community-associated CDI.

Results: Of 67 CDI patients studied, 54 (81%) had 1 or more outpatient visits within 12 weeks after diagnosis. Of 44 patients cultured during outpatient visits, 14 (32%) had skin contamination and 12 (27%) contaminated environmental surfaces. Decreased mobility, fecal incontinence, and treatment with non-CDI antibiotics were associated with positive cultures, whereas vancomycin taper therapy was protective. In patients not on CDI therapy, a prediction rule including incontinence or decreased mobility was 90% sensitive and 79% specific for detection of spore shedding. Of 84 clinic and emergency department rooms cultured, 12 (14%) had 1 or more contaminated environmental sites. For 33 community-associated CDI cases, 31 (94%) had an outpatient visit during the 12 weeks prior to onset of diarrhea.

Conclusions: Patients with recent CDI present a significant risk for transmission of spores during outpatient visits. The outpatient setting may be an underappreciated source of community-associated CDI cases.

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Related in: MedlinePlus

Proposed algorithm for management of patients with recent Clostridium difficile infection (CDI) presenting to outpatient clinics.Enhanced precautions includes wearing gloves when examining patients and cleaning high-touch surfaces with sporicidal disinfectants after visits.
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pone-0070175-g002: Proposed algorithm for management of patients with recent Clostridium difficile infection (CDI) presenting to outpatient clinics.Enhanced precautions includes wearing gloves when examining patients and cleaning high-touch surfaces with sporicidal disinfectants after visits.

Mentions: Our findings have important implications for infection control of C. difficile in outpatient settings. Clinicians should be aware that patients with recent CDI may have skin contamination and that spores may be spread to environmental surfaces during outpatient visits. Based on our findings, figure 2 provides a proposed algorithm for management of patients with recent CDI presenting to outpatient clinics. Patients on CDI therapy for ≤2 weeks are at high risk for transmission, particularly during the first few days of therapy [7], and should be managed with enhanced precautions including wearing gloves when examining patients and cleaning high-touch surfaces with sporicidal disinfectants after visits. Similarly, patients diagnosed with CDI in the past 2–12 weeks but not on current therapy should be managed with enhanced precautions if they are immobile or have fecal incontinence. Such measures might be particularly indicated in clinics where many patients are at risk for CDI due to antibiotic therapy (e.g., oncology and infectious diseases clinics). Given the small sample size of our study, the proposed algorithm should be considered preliminary and further studies will be needed for validation.


Outpatient healthcare settings and transmission of Clostridium difficile.

Jury LA, Sitzlar B, Kundrapu S, Cadnum JL, Summers KM, Muganda CP, Deshpande A, Sethi AK, Donskey CJ - PLoS ONE (2013)

Proposed algorithm for management of patients with recent Clostridium difficile infection (CDI) presenting to outpatient clinics.Enhanced precautions includes wearing gloves when examining patients and cleaning high-touch surfaces with sporicidal disinfectants after visits.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3722238&req=5

pone-0070175-g002: Proposed algorithm for management of patients with recent Clostridium difficile infection (CDI) presenting to outpatient clinics.Enhanced precautions includes wearing gloves when examining patients and cleaning high-touch surfaces with sporicidal disinfectants after visits.
Mentions: Our findings have important implications for infection control of C. difficile in outpatient settings. Clinicians should be aware that patients with recent CDI may have skin contamination and that spores may be spread to environmental surfaces during outpatient visits. Based on our findings, figure 2 provides a proposed algorithm for management of patients with recent CDI presenting to outpatient clinics. Patients on CDI therapy for ≤2 weeks are at high risk for transmission, particularly during the first few days of therapy [7], and should be managed with enhanced precautions including wearing gloves when examining patients and cleaning high-touch surfaces with sporicidal disinfectants after visits. Similarly, patients diagnosed with CDI in the past 2–12 weeks but not on current therapy should be managed with enhanced precautions if they are immobile or have fecal incontinence. Such measures might be particularly indicated in clinics where many patients are at risk for CDI due to antibiotic therapy (e.g., oncology and infectious diseases clinics). Given the small sample size of our study, the proposed algorithm should be considered preliminary and further studies will be needed for validation.

Bottom Line: For 33 community-associated CDI cases, 31 (94%) had an outpatient visit during the 12 weeks prior to onset of diarrhea.Patients with recent CDI present a significant risk for transmission of spores during outpatient visits.The outpatient setting may be an underappreciated source of community-associated CDI cases.

View Article: PubMed Central - PubMed

Affiliation: Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America.

ABSTRACT

Background: Recent reports suggest that community-associated Clostridium difficile infection (CDI) (i.e., no healthcare facility admission within 90 days) may be increasing in frequency. We hypothesized that outpatient clinics could be an important source for acquisition of community-associated CDI.

Methods: We performed a 6-month prospective study of CDI patients to determine frequency of and risk factors for skin and environmental shedding during outpatient visits and to derive a prediction rule for positive cultures. We performed a point-prevalence culture survey to assess the frequency of C. difficile contamination in outpatient settings and evaluated the frequency of prior outpatient visits in patients with community-associated CDI.

Results: Of 67 CDI patients studied, 54 (81%) had 1 or more outpatient visits within 12 weeks after diagnosis. Of 44 patients cultured during outpatient visits, 14 (32%) had skin contamination and 12 (27%) contaminated environmental surfaces. Decreased mobility, fecal incontinence, and treatment with non-CDI antibiotics were associated with positive cultures, whereas vancomycin taper therapy was protective. In patients not on CDI therapy, a prediction rule including incontinence or decreased mobility was 90% sensitive and 79% specific for detection of spore shedding. Of 84 clinic and emergency department rooms cultured, 12 (14%) had 1 or more contaminated environmental sites. For 33 community-associated CDI cases, 31 (94%) had an outpatient visit during the 12 weeks prior to onset of diarrhea.

Conclusions: Patients with recent CDI present a significant risk for transmission of spores during outpatient visits. The outpatient setting may be an underappreciated source of community-associated CDI cases.

Show MeSH
Related in: MedlinePlus