title: Clostridium difficile infection in a long-term care facility: hospital-associated illness compared with long-term care-associated illness.
abstract: BACKGROUND
  Controversy exists over whether Clostridium difficile infection (CDI) commonly occurs in long-term care facility residents who have not been recently transferred from an acute care hospital.
  
  
  OBJECTIVE
  To assess the incidence and outcome of CDI in a long-term care facility.
  
  
  METHODS
  Retrospective cohort study in a 262-bed long-term care Veterans Affairs facility in Pittsburgh, Pennsylvania, for the period January 2004 through June 2010. CDI was identified by positive stool C. difficile toxin assay and acute diarrhea. Patients were categorized as hospital-associated CDI (HACDI) or long-term care facility-associated CDI (LACDI) and followed for 6 months.
  
  
  RESULTS
  The annual rate of CDI varied between 0.11 and 0.23 per 1,000 resident-days for HACDI patients and between 0.04 and 0.28 per 1,000 resident-days for LACDI patients. We identified 162 patients, 96 patients (59.3%) with HACDI and 66 patients (40.7%) with LACDI. Median age was 74 and 77 years, respectively, for HACDI and LACDI (P = .055) patients. There were more patients with at least 1 relapse of CDI during 6 months of follow up in LACDI patients (32/66, 48.5%) than in HACDI patients (28/96, 29.2%; P = .005). Logistic regression showed that ages of at least 75 years (odds ratio [OR], 2.33; 95% confidence interval [CI], 1.07-5.07; P = .005), more than 2 transfers to an acute care hospital (OR, 7.88; 95% CI, 1.88-32.95; P = .005), and LACDI (OR, 3.15; 95% CI, 1.41-7.05; P = .005) were associated with relapse of CDI.
  
  
  CONCLUSIONS
  Forty percent of CDI cases were acquired within the long-term care facility, indicating a substantial degree of transmission. Optimal strategies to prevent CDI in the long-term care facility are needed.
authors.affiliation: Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Jong Hun
authors.initials: JH
authors.lastname: Kim
authors.forename: Diana
authors.initials: D
authors.lastname: Toy
authors.forename: Robert R
authors.initials: RR
authors.lastname: Muder
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016360:Clostridioides difficile; D003015:Clostridium Infections / Q000453:epidemiology*; D015331:Cohort Studies; D003428:Cross Infection / Q000453:epidemiology*; D005260:Female; D006761:Hospitals; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D012866:Skilled Nursing Facilities