title: Onset of symptoms and time to diagnosis of Clostridium difficile-associated disease following discharge from an acute care hospital.
abstract: OBJECTIVE
  To identify patients with a diagnosis of Clostridium difficile-associated disease (CDAD) in the ambulatory care setting and determine the relationship of symptom onset and diagnosis to prior hospitalization and exposure to antimicrobials.
  
  
  METHODS
  Single-center, retrospective study.
  
  
  METHODS
  Medical records were reviewed for outpatients and hospitalized patients with a stool assay positive for C. difficile toxin A from January 1998 through March 2005. Patients with recurrent CDAD or residing in an extended-care facility were excluded. CDAD in patients who had been hospitalized in the 100 days prior to diagnosis was considered potentially hospital-associated.
  
  
  RESULTS
  Of the 84 patients who met the inclusion criteria, 75 (89%) received a diagnosis 1-60 days after hospital discharge (median, 12 days), and 71 (85%) received a diagnosis within 30 days after discharge. Of the 69 patients whose records contained information regarding time of symptom onset, 62 (90%) developed diarrhea within 30 days of a previous hospital discharge, including 7 patients with symptom onset prior to discharge and 9 with onset on the day of discharge. The median time from symptom onset to diagnosis was 6 days. Of 84 patients, 77 (92%) had received antimicrobials during a prior hospitalization, but 55 (65%) received antimicrobials both as inpatients and as outpatients.
  
  
  CONCLUSIONS
  If all cases of CDAD diagnosed within 100 days of hospital discharge were assumed to be hospital-associated, 71 (85%) of 84 patients with CDAD were identified within 30 days, and 75 (89%) of 84 were identified by day 60. Continued outpatient antimicrobial exposure confounds determination of whether late-onset cases are community- or hospital-associated.
authors.affiliation: Department of Veterans Affairs, Midwest Center for Health Services and Policy Research and Research Service, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL 60141, USA.
authors.forename: Heidi T
authors.initials: HT
authors.lastname: Chang
authors.forename: Dorota
authors.initials: D
authors.lastname: Krezolek
authors.forename: Stuart
authors.initials: S
authors.lastname: Johnson
authors.forename: Jorge P
authors.initials: JP
authors.lastname: Parada
authors.forename: Charlesnika T
authors.initials: CT
authors.lastname: Evans
authors.forename: Dale N
authors.initials: DN
authors.lastname: Gerding
mesh_terms: D000900:Anti-Bacterial Agents / Q000009:adverse effects*; D001426:Bacterial Proteins / Q000032:analysis; D001427:Bacterial Toxins / Q000032:analysis; D016360:Clostridioides difficile / Q000472:pathogenicity*; D017714:Community-Acquired Infections / Q000382:microbiology; D003428:Cross Infection / Q000382:microbiology*; D004768:Enterotoxins / Q000032:analysis; D005243:Feces / Q000382:microbiology*; D016908:Gram-Positive Bacterial Infections / Q000175:diagnosis*; D006787:Hospitals, Veterans; D006801:Humans; D007297:Inpatients; D008485:Medical Audit; D010045:Outpatients; D010351:Patient Discharge; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents; D001426:Bacterial Proteins; D001427:Bacterial Toxins; D004768:Enterotoxins; C041348:tcdA protein, Clostridium difficile; C031815:toxB protein, Clostridium difficile