title: Burden of Nursing Home-Onset Clostridium difficile Infection in the United States: Estimates of Incidence and Patient Outcomes.
abstract: Background.  Approximately 4 million Americans receive nursing home (NH) care annually. Nursing home residents commonly have risk factors for Clostridium difficile infection (CDI), including advanced age and antibiotic exposures. We estimated national incidence of NH-onset (NHO) CDI and patient outcomes. Methods.  We identified NHO-CDI cases from population-based surveillance of 10 geographic areas in the United States. Cases were defined by C difficile-positive stool collected in an NH (or from NH residents in outpatient settings or ≤3 days after hospital admission) without a positive stool in the prior 8 weeks. Medical records were reviewed on a sample of cases. Incidence was estimated using regression models accounting for age and laboratory testing method; sampling weights were applied to estimate hospitalizations, recurrences, and deaths. Results.  A total of 3503 NHO-CDI cases were identified. Among 262 sampled cases, median age was 82 years, 76% received antibiotics in the 12 weeks prior to the C difficile-positive specimen, and 57% were discharged from a hospital in the month before specimen collection. After adjusting for age and testing method, the 2012 national estimate for NHO-CDI incidence was 112 800 cases (95% confidence interval [CI], 93 400-131 800); 31 400 (28%) were hospitalized within 7 days after a positive specimen (95% CI, 25 500-37 300), 20 900 (19%) recurred within 14-60 days (95% CI, 14 600-27 100), and 8700 (8%) died within 30 days (95% CI, 6600-10 700). Conclusions.  Nursing home onset CDI is associated with substantial morbidity and mortality. Strategies focused on infection prevention in NHs and appropriate antibiotic use in both NHs and acute care settings may decrease the burden of NHO CDI.
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases; Division of Scientific Education and Professional Development, Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: Hunter
authors.affiliation: Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases.
authors.forename: Yi
authors.initials: Y
authors.lastname: Mu
authors.affiliation: University of Rochester Medical Center , New York.
authors.forename: Ghinwa K
authors.initials: GK
authors.lastname: Dumyati
authors.affiliation: Department of Medicine, Emory University School of Medicine; Atlanta Veterans Affairs Medical Center, Georgia.
authors.forename: Monica M
authors.initials: MM
authors.lastname: Farley
authors.affiliation: Department of Medicine , University of California, San Francisco School of Medicine.
authors.forename: Lisa G
authors.initials: LG
authors.lastname: Winston
authors.affiliation: Colorado Department of Public Health and Environment, Denver.
authors.forename: Helen L
authors.initials: HL
authors.lastname: Johnston
authors.affiliation: Connecticut Emerging Infections Program , Yale School of Public Health , New Haven.
authors.forename: James I
authors.initials: JI
authors.lastname: Meek
authors.affiliation: Maryland Department of Health and Mental Hygiene, Baltimore.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Perlmutter
authors.affiliation: Minnesota Department of Health, St. Paul; Division of State and Local Readiness, Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response, Atlanta, Georgia.
authors.forename: Stacy M
authors.initials: SM
authors.lastname: Holzbauer
authors.affiliation: Public Health Division , Oregon Health Authority , Portland.
authors.forename: Zintars G
authors.initials: ZG
authors.lastname: Beldavs
authors.affiliation: New Mexico Emerging Infections Program , University of New Mexico , Albuquerque.
authors.forename: Erin C
authors.initials: EC
authors.lastname: Phipps
authors.affiliation: Tennessee Department of Health, Nashville.
authors.forename: John R
authors.initials: JR
authors.lastname: Dunn
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases; Atlanta Research and Education Foundation, Georgia.
authors.forename: Jessica A
authors.initials: JA
authors.lastname: Cohen
authors.affiliation: Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases.
authors.forename: Johannetsy
authors.initials: J
authors.lastname: Avillan
authors.affiliation: Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases.
authors.forename: Nimalie D
authors.initials: ND
authors.lastname: Stone
authors.affiliation: Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois.
authors.forename: Dale N
authors.initials: DN
authors.lastname: Gerding
authors.affiliation: Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases.
authors.forename: L Clifford
authors.initials: LC
authors.lastname: McDonald
authors.affiliation: Division of Healthcare Quality Promotion , Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases.
authors.forename: Fernanda C
authors.initials: FC
authors.lastname: Lessa
keywords: Clostridium difficile; long-term care facility; nursing home