About 10% of patients admitted to a hospital carried Clostridioides difficile, even though they had no active symptoms of the infection, researchers found.
Moreover, almost 40% of these carriers eventually developed symptoms of C. difficile infection versus about 2% of non-carriers, reported Sarah Baron, MD, of Montefiore Medical Center in New York City, writing in , the journal of the Society for Healthcare Epidemiology of America.
"It has generally been assumed that patients get the bacteria during their stay in the hospital," Baron said in a statement. "These findings might mean that we can predict who will develop C. diff and try to stop it before it starts."
Indeed, the authors noted that carriers of C. difficile could serve as reservoirs to transmit the infection to other patients, as these carriers are not "routinely identified" upon admission to the hospital.
They cited two potential ways that identifying these carriers earlier could potentially help reduce the spread of the infection:
"Isolation of C. difficile carriers could reduce transmission to uninfected patients, and ... interventions targeting C. difficile carriers could potentially prevent progression to symptomatic C. difficile," the authors wrote.
Researchers examined a cohort of patients admitted to a large university hospital in New York City from July 2017 to March 2018. Patients without diarrhea upon admission were tested for C. difficile and then followed prospectively through electronic health records for 6 months, until death, or a diagnosis of symptomatic C. difficile infection. They noted that nursing facility residents were enrolled in a 4:1 sampling strategy.
Overall, 220 patients were enrolled. A little over half were women, over two-thirds were age 65 or older, and 55% did not have a soiled swab, or visible fecal material on the swab. There were 21 patients who were asymptomatic C. difficile carriers, including 17 of 168 nursing facility residents and 4 of 52 community residents.
Having a soiled swab was associated with carriage (OR 2.7, 95% CI 1.03-6.9, P=0.04), the authors noted, and was the only clinical or demographic feature that was linked to carriage.
"We hypothesize that swab soilage represents improved testing sensitivity in the presence of frank fecal material or, instead, could mean stool incontinence, poor hygiene, or an inability to care for oneself effectively," they wrote.
Interestingly, previous antibiotic exposure had a non-significant link with asymptomatic carriage (OR 2.3, 95% CI 0.9-5.6, P=0.08).
Of the 21 asymptomatic carriers, 8 had clinical C. difficile infection within 6 months, and most progressed within 2 weeks of enrollment.
Limitations to the data include limited power to detect a difference in the portion of nursing residents and community residents who were carriers, due to a lower number of carriers than expected. They also noted that symptomatic C. difficile could have been underestimated, since asking about development of symptoms was left to the primary team. In addition, they used perirectal as opposed to rectal swabbing or stool specimens to detect C. difficile.
"Specific environmental, isolation, and stewardship strategies to prevent spread of C. difficile from carriers to uninfected patients as well as prevent progression to symptomatic [infection] warrant further study," the authors concluded.
Disclosures
This study was supported by the NIH/National Center for Advancing Translational Science Montefiore CFSA, as well as additional support from Montefiore Medical Center, Albert Einstein College of Medicine.
The authors disclosed no conflicts of interest.
Primary Source
Infection Control & Hospital Epidemiology
Baron SW, et al "Screening of Clostridioides difficile carriers in an urban academic medical center: Understanding implications of disease" Infect Control Hosp Epidemiol 2019; DOI: 10.1017/ice.2019.309.