Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study

• Published in: Open forum infectious diseases 2017-10, Vol.4 (4), p.ofx171
• Main Authors: Guh, Alice Y, Adkins, Susan Hocevar, Li, Qunna, Bulens, Sandra N, Farley, Monica M, Smith, Zirka, Holzbauer, Stacy M, Whitten, Tory, Phipps, Erin C, Hancock, Emily B, Dumyati, Ghinwa, Concannon, Cathleen, Kainer, Marion A, Rue, Brenda, Lyons, Carol, Olson, Danyel M, Wilson, Lucy, Perlmutter, Rebecca, Winston, Lisa G, Parker, Erin, Bamberg, Wendy, Beldavs, Zintars G, Ocampo, Valerie, Karlsson, Maria, Gerding, Dale N, McDonald, L Clifford
• Format: Article
• Language: English
• Subjects: Editor's Choice; Major
• ISSN: 2328-8957; 2328-8957
• DOI: 10.1093/ofid/ofx171

Abstract Background An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors. Methods We enrolled participants from 10 US sites during October 2014–March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed. Results Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure—that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13–321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01–311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77–340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76–340.05),—emergency department visit (AmOR, 17.37; 95% CI, 1.99–151.22), white race (AmOR 7.67; 95% CI, 2.34–25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20–19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24–118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27–20.79) were associated with CA-CDI. Conclusions Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed.