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Transmission of Clostridium difficile from asymptomatically colonized or infected long-term care facility residents

  • Curtis J. Donskey (a1), Venkata C. K. Sunkesula (a2), Nimalie D. Stone (a3), Carolyn V. Gould (a3), L. Clifford McDonald (a3), Matthew Samore (a4), JeanMarie Mayer (a5), Susan M. Pacheco (a5), Annette L. Jencson (a2), Susan P. Sambol (a5), Laurica A. Petrella (a6), Christopher A. Gulvik (a3) and Dale N. Gerding (a6) (a7)...

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.

Copyright

Corresponding author

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

References

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1. Lessa, FC, Mu, Y, Bamberg, WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med 2015;372:825834.
2. Guerrero, DM, Nerandzic, MM, Jury, LA, Chang, S, Jump, RL, Donskey, CJ. Clostridium difficile infection in a Department of Veterans Affairs long-term care facility. Infect Control Hosp Epidemiol 2011;32:513515.
3. Pawar, D, Tsay, R, Nelson, DS, Elumalai, MK, Lessa, FC, Clifford McDonald, L, Dumyati, G. Burden of Clostridium difficile infection in long-term care facilities in Monroe County, New York. Infect Control Hosp Epidemiol 2012;33:11071112.
4. Hunter, JC, Mu, Y, Dumyati, GK, et al. Burden of nursing home-onset Clostridium difficile infection in the United States: estimates of incidence and patient outcomes. Open Forum Infect Dis 2016;3:ofv196.
5. Kazakova, S, Ware, K, Baughman, B, et al. A hospital outbreak of diarrhea due to an emerging epidemic strain of Clostridium difficile . Arch Intern Med 2006;166:25182524.
6. Riggs, MM, Sethi, AK, Zabarsky, TF, Eckstein, EC, Jump, RL, Donskey, CJ. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007;45:992998.
7. Jinno, S, Kundrapu, S, Guerrero, DM, Jury, LA, Nerandzic, MM, Donskey, CJ. Potential for transmission of Clostridium difficile by asymptomatic acute care patients and long-term care facility residents with prior C. difficile infection. Infect Control Hosp Epidemiol 2012;33:638639.
8. Dubberke, ER, Carling, P, Carrico, R, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 Update. Infect Control Hosp Epidemiol 2014;35:628645.
9. Roup, B, Roche, J, Pass, M. Infection control program disparities between acute and long-term care facilities in Maryland. Am J Infect Control 2006;34:122127.
10. Mylotte, J. Surveillance for Clostridium difficile-associated diarrhea in long-term care facilities: what you get is not what you see. Infect Control Hosp Epidemiol 2008;29:760763.
11. Kim, JH, Toy, D, Muder, RR. Clostridium difficile infection in a long-term care facility: hospital-associated illness compared with long-term care-associated illness. Infect Control Hosp Epidemiol 2011;32:656660.
12. Curry, SR, Muto, CA, Schlackman, JL, Pasculle, AW, Shutt, KA, Marsh, JW, Harrison, LH. Use of multilocus variable number of tandem repeats analysis genotyping to determine the role of asymptomatic carriers in Clostridium difficile transmission. Clin Infect Dis 2013;57:10941102.
13. Longtin, Y, Paquet-Bolduc, B, Gilca, R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Intern Med 2016;176:796804.
14. Blixt, T, Gradel, KO, Homann, C, et al. Asymptomatic carriers contribute to nosocomial Clostridium difficile infection: a cohort study of 4508 patients. Gastroenterol 2017;152:10311041.
15. Donskey, CJ, Sunkesula, VC, Jencson, AL, et al. Utility of a commercial PCR assay and a clinical prediction rule for detection of toxigenic Clostridium difficile in asymptomatic carriers. J Clin Microbiol 2014;52:315318.
16. Sethi, AK, Al-Nassir, WN, Nerandzic, MM, et al. Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C. difficile infection. Infect Control Hosp Epidemiol 2010;31:2127.
17. Ponnada, S, Guerrero, DM, Jury, LA, Nerandzic, MM, Cadnum, JL, Alam, MJ, Donskey, CJ. Acquisition of Clostridium difficile colonization and infection after transfer from a Veterans Affairs hospital to an affiliated long-term care facility. Infect Control Hosp Epidemiol 2017;38:10701076.
18. Sitzlar, B, Deshpande, A, Fertelli, D, Kundrapu, S, Sethi, AK, Donskey, CJ. An environmental disinfection odyssey: evaluation of sequential interventions to improve disinfection of Clostridium difficile isolation rooms. Infect Control Hosp Epidemiol 2013;34:459465.
19. Donskey, CJ, Kundrapu, S, Deshpande, A. Colonization versus carriage of Clostridium difficile . Infect Dis Clin North Am 2015;29:1328.
20. Clabots, CR, Johnson, S, Bettin, KM, et al. Development of a rapid and efficient restriction endonuclease analysis typing system for Clostridium difficile and correlation with other typing systems. J Clin Microbiol 1993;31:18701875.
21. Cox, MP, Peterson, DA, Biggs, PJ. SolexaQA: At-a-glance quality assessment of Illumina second-generation sequencing data. BMC Bioinformatics 2010;11:485.
22. Peng, Y, Leung, HC, Yiu, SM, Chin, FY. IDBA-UD: a de novo assembler for single-cell and metagenomic sequencing data with highly uneven depth. Bioinformatics 2012;28:14201428.
23. Darling, AE, Mau, B, Perna, NT. ProgressiveMauve: multiple genome alignment with gene gain, loss and rearrangement. PLoS One 2010;5:e11147.
24. Didelot, X, Wilson, DJ. ClonalFrameML: efficient inference of recombination in whole bacterial genomes. PLoS Comput Biol 2015;11:e1004041.
25. Guindon, S, Dufayard, JF, Lefort, V, Anisimova, M, Hordijk, W, Gascuel, O. New algorithms and methods to estimate maximum-likelihood phylogenies: assessing the performance of PhyML 3.0. Syst Biol 2010;59:307321.
26. Eyre, DW, Cule, ML, Wilson, DJ, et al. Diverse sources of C. difficile infection identified on whole-genome sequencing. N Engl J Med 2013;369:11951205.
27. Johnson, S, Petrella, L, Siddiqui, F, et al. Emergence of a new C. difficile strain, REA group DQ related to REA group BI/ribotype 027. 13th Biennial Congress of the Anaerobe Society of the Americas. Nashville, TN, July 11–14, 2016. Abstract# PIII-3.
28. Guerrero, DM, Becker, JC, Eckstein, EC, et al. Asymptomatic carriage of toxigenic Clostridium difficile by hospitalized patients. J Hosp Infect 2013;85:155158.
29. Jury, LA, Tomas, M, Kundrapu, S, Sitzlar, B, Donskey, CJ. A Clostridium difficile infection (CDI) stewardship initiative improves adherence to practice guidelines for management of CDI. Infect Control Hosp Epidemiol 2013;34:12221224.
30. Eyre, DW, Walker, AS, Griffiths, D, et al. Clostridium difficile mixed infection and reinfection. J Clin Microbiol 2012;50:142144.
31. Datta, R, Brown, S, Nguyen, VQ, et al. Quantifying the exposure to antibiotic-resistant pathogens among patients discharged from a single hospital across all California healthcare facilities. Infect Control Hosp Epidemiol 2015;36:12751282.
32. Wiener, J, Quinn, JP, Bradford, PA, Goering, RV, Nathan, C, Bush, K, Weinstein, RA. Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes. JAMA 1999;281:517523.
33. Pop-Vicas, AE, D’Agata, EM. The rising influx of multidrug-resistant gram-negative bacilli into a tertiary care hospital. Clin Infect Dis 2005;40:17921798.
34. D’Agata, EM, Habtemariam, D, Mitchell, S. Multidrug-resistant gram-negative bacteria: inter- and intradissemination among nursing homes of residents with advanced dementia. Infect Control Hosp Epidemiol 2015;36:930935.
35. Harrison, EM, Ludden, C, Brodrick, HJ, et al. Transmission of methicillin-resistant Staphylococcus aureus in long-term care facilities and their related healthcare networks. Genome Med 2016;8:102.
36. Trick, WE, Kuehnert, MJ, Quirk, SB, et al. Regional dissemination of vancomycin-resistant enterococci resulting from interfacility transfer of colonized patients. J Infect Dis 1999;180:391396.
37. Brodrick, HJ, Raven, KE, Harrison, EM, et al. Whole-genome sequencing reveals transmission of vancomycin-resistant Enterococcus faecium in a healthcare network. Genome Med 2016;8:4.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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