Te drivers of acute and long-term care clostridium dificile infection rates: A retrospective multilevel cohort study of 251 facilities

Abstract

Background: Drivers of differences in Clostridium dificile incidence across acute and long-term care facilities are poorly understood. We sought to obtain a comprehensive picture of C. dificile incidence and risk factors in acute and long-term care. Methods: We conducted a case-cohort study of persons spending at least 3 days in one of 131 acute care or 120 long-term care facilities managed by the United States Veterans Health Administration between 2006 and 2012. Patient (n = 8) and facility factors (n = 5) were included in analyses. The outcome was the incidence of facility-onset laboratory-identified C. dificile infection (CDI), defined as a person with a positive C. dificile test without a positive test in the prior 8 weeks. Results: CDI incidence in acute care was 5 times that observed in long-term care (median, 15.6 vs 3.2 per 10 000 person-days). History of antibiotic use was greater in acute care compared to long-term care (median, 739 vs 513 per 1000 person-days) and explained 72% of the variation in C. dificile rates. Importation of C. dificile cases (acute care: patients with recent long-term care attributable infection; long-term care: residents with recent acute care attributable infection) was 3 times higher in long-term care as compared to acute care (median, 52.3 vs 16.2 per 10 000 person-days). Conclusions. Facility-level antibiotic use was the main factor driving differences in CDI incidence between acute and long-term care. Importation of acute care C. dificile cases was a greater concern for long-term care as compared to importation of long-term care cases for acute care.