title: Impact of Toxigenic Clostridium difficile Colonization on the Risk of Subsequent C. difficile Infection in Intensive Care Unit Patients.
abstract: BACKGROUND
  Clostridium difficile infection (CDI) in hospitalized patients is generally attributed to the current stay, but recent studies reveal high C. difficile colonization rates on admission.
  
  
  OBJECTIVE
  To determine the rate of colonization with toxigenic C. difficile among intensive care unit patients upon admission as well as acquired during hospitalization, and the risk of subsequent CDI.
  
  
  METHODS
  Prospective cohort study from April 15 through July 8, 2013. Adults admitted to an intensive care unit within 48 hours of admission to the Johns Hopkins Hospital, Baltimore, Maryland, were screened for colonization with toxigenic C. difficile. The primary outcome was risk of developing CDI.
  
  
  RESULTS
  Among 542 patients, 17 (3.1%) were colonized with toxigenic C. difficile on admission and an additional 3 patients were found to be colonized during hospitalization. Both colonization with toxigenic C. difficile on admission and colonization during hospitalization were associated with an increased risk for development of CDI (relative risk, 10.29 [95% CI, 2.24-47.40], P=.003; and 15.66 [4.01-61.08], P<.001, respectively). Using multivariable analysis, colonization on admission and colonization during hospitalization were independent predictors of CDI (relative risk, 8.62 [95% CI, 1.48-50.25], P=.017; and 10.93 [1.49-80.20], P=.019, respectively), while adjusting for potential confounders.
  
  
  CONCLUSIONS
  In intensive care unit patients, colonization with toxigenic C. difficile is an independent risk factor for development of subsequent CDI. Further studies are needed to identify populations with higher toxigenic C. difficile colonization rates possibly benefiting from screening or avoidance of agents known to promote CDI.
authors.affiliation: 1Division of Infectious Diseases,Department of Medicine,Johns Hopkins University School of Medicine,Baltimore,Maryland.
authors.forename: Sarah
authors.initials: S
authors.lastname: Tschudin-Sutter
authors.affiliation: 4Division of Medical Microbiology,Department of Pathology,Johns Hopkins Medical Institutions,Baltimore,Maryland.
authors.forename: Karen C
authors.initials: KC
authors.lastname: Carroll
authors.affiliation: 5Division of Pediatric Infectious Diseases,Department of Pediatrics,Johns Hopkins University School of Medicine,Baltimore,Maryland.
authors.forename: Pranita D
authors.initials: PD
authors.lastname: Tamma
authors.affiliation: 1Division of Infectious Diseases,Department of Medicine,Johns Hopkins University School of Medicine,Baltimore,Maryland.
authors.forename: Madeleine L
authors.initials: ML
authors.lastname: Sudekum
authors.affiliation: 6Division of Clinical Microbiology,University Hospital Basel,Basel,Switzerland.
authors.forename: Reno
authors.initials: R
authors.lastname: Frei
authors.affiliation: 2Division of Infectious Diseases and Hospital Epidemiology,University Hospital Basel,Basel,Switzerland.
authors.forename: Andreas F
authors.initials: AF
authors.lastname: Widmer
authors.affiliation: 4Division of Medical Microbiology,Department of Pathology,Johns Hopkins Medical Institutions,Baltimore,Maryland.
authors.forename: Brandon C
authors.initials: BC
authors.lastname: Ellis
authors.affiliation: 1Division of Infectious Diseases,Department of Medicine,Johns Hopkins University School of Medicine,Baltimore,Maryland.
authors.forename: John
authors.initials: J
authors.lastname: Bartlett
authors.affiliation: 1Division of Infectious Diseases,Department of Medicine,Johns Hopkins University School of Medicine,Baltimore,Maryland.
authors.forename: Trish M
authors.initials: TM
authors.lastname: Perl
mesh_terms: D000328:Adult; D000368:Aged; D015142:Baltimore; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000175:diagnosis*; D003428:Cross Infection / Q000175:diagnosis*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors