title: Outpatient healthcare settings and transmission of Clostridium difficile.
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.
authors.affiliation: Geriatric Research Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, United States of America.
authors.forename: Lucy A
authors.initials: LA
authors.lastname: Jury
authors.forename: Brett
authors.initials: B
authors.lastname: Sitzlar
authors.forename: Sirisha
authors.initials: S
authors.lastname: Kundrapu
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Cadnum
authors.forename: Kim M
authors.initials: KM
authors.lastname: Summers
authors.forename: Christine P
authors.initials: CP
authors.lastname: Muganda
authors.forename: Abhishek
authors.initials: A
authors.lastname: Deshpande
authors.forename: Ajay K
authors.initials: AK
authors.lastname: Sethi
authors.forename: Curtis J
authors.initials: CJ
authors.lastname: Donskey
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016360:Clostridioides difficile / Q000302:isolation & purification / Q000472:pathogenicity*; D003015:Clostridium Infections / Q000635:transmission*; D005260:Female; D006268:Health Facilities; D006801:Humans; D008297:Male; D008875:Middle Aged; D010045:Outpatients / Q000706:statistics & numerical data; D011446:Prospective Studies; D013171:Spores, Bacterial / Q000472:pathogenicity
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