Division of Gastroenterology, Department of Medicine, Johns Hopkins University, Sinai Hospital of Baltimore, Baltimore, MD, USA.
Dig Dis Sci. 2013 Dec;58(12):3407-12. doi: 10.1007/s10620-013-2848-x. Epub 2013 Oct 24.
Previous epidemiological studies on Clostridium-difficile-Associated Diarrhea (CDAD) have focused on hospitalized patients with nosocomial transmission. However, increasing numbers of patients with CDAD are being admitted to acute-care hospitals from long-term care facilities (LTCFs) and the local community. The purpose of our study was to study the changing epidemiological trends of CDAD patients admitted to an acute-care hospital and examine factors contributing to this shift in epidemiology.
This IRB-approved retrospective study included 400 randomly selected patients with a diagnosis of CDAD, admitted to an acute-care hospital between January, 2005 and December, 2010. CDAD was defined as ≥3 episodes of loose stools in <24 h with a positive Clostridium difficile stool toxin assay. The patients were divided into three groups: hospital-acquired CDAD, long-term care facility (LTCF)-acquired CDAD, and community-acquired CDAD. The groups were compared in terms of demographics, ICU admissions, hospital length of stay, co-morbidities, presenting complaint, and medication use. Patients who were hospitalized in the preceding 12 weeks or who had history of antibiotic use in the prior 8 weeks were excluded.
Final analysis included 258 toxin-positive CDAD patients. Only 53 (20.6%) patients had hospital-acquired CDAD. Patients from LTCFs (n=119, 46.1%) and the community (86 patients, 33.3%) comprised 79.4% of patients. The mean age for LTCF population was significantly higher than the hospital-acquired and community-acquired CDAD groups (p<0.0001). The presenting complaint was categorized as diarrhea or non-diarrheal symptom. Other non-diarrheal symptoms included fever, abdominal pain and altered mental status. Only 15.2% of LTCF patients had diarrhea as their presenting complaint (n=18) as compared to 29.1% of patients from the community (n=25; p<0.05). Most LTCF patients (n=101, 84.8%) had non-diarrheal symptoms as their presenting complaint as compared to only 61 patients from the community (70.9%) (p<0.05). Use of proton pump inhibitor (PPI) was more frequent in LTCF patients (73%) and patients with hospital-acquired CDAD (69.8%) as compared to patients with community-acquired CDAD (43%) (p<0.05). No valid indication was found for PPI use in 24.13% of LTCF patients and 32.1% of patients with community-acquired CDAD as compared to only 12.9% of patients with hospital-acquired CDAD.
These observations suggest that CDAD originated predominantly in patients from LTCFs (46.1%) and community (33.3%) rather than from hospitalized patients (20.6%). Diarrhea was the presenting complaint in LTCF patients in only 15.2% of cases. Hence, CDAD should be suspected if LTCF patients present with symptoms such as abdominal pain, fever, or altered mental status along with loose stools. Majority of the LTCF patients were found to be on PPIs, a risk factor for CDAD, with as many as 24% of these patients with no valid indication for their use.
先前关于艰难梭菌相关性腹泻（CDAD）的流行病学研究主要集中在医院获得性、具有医院内传播的住院患者上。然而，越来越多的 CDAD 患者从长期护理机构（LTCF）和当地社区被收入急性护理医院。我们研究的目的是研究收入急性护理医院的 CDAD 患者的流行病学变化趋势，并探讨导致这种流行病学变化的因素。
这项经过机构审查委员会批准的回顾性研究包括了 400 名随机选择的、被诊断为 CDAD 的患者，他们在 2005 年 1 月至 2010 年 12 月期间被收入急性护理医院。CDAD 的定义为<24 小时内出现≥3 次稀便，且艰难梭菌粪便毒素检测呈阳性。患者被分为三组：医院获得性 CDAD、长期护理机构（LTCF）获得性 CDAD 和社区获得性 CDAD。将这三组患者在人口统计学、入住重症监护病房、住院时间、合并症、就诊主诉和药物使用方面进行比较。排除了在过去 12 周内住院或在过去 8 周内使用过抗生素的患者。
最终分析包括 258 例毒素阳性 CDAD 患者。仅有 53 例（20.6%）患者为医院获得性 CDAD。来自 LTCF（n=119，46.1%）和社区（86 例，33.3%）的患者占 79.4%。LTCF 患者的平均年龄显著高于医院获得性和社区获得性 CDAD 组（p<0.0001）。就诊主诉分为腹泻或非腹泻症状。其他非腹泻症状包括发热、腹痛和精神状态改变。仅有 15.2%的 LTCF 患者（n=18）以腹泻为主要主诉，而社区患者（n=25，29.1%）腹泻的比例较低（p<0.05）。大多数 LTCF 患者（n=101，84.8%）以非腹泻症状为主要主诉，而社区患者仅有 61 例（70.9%）（p<0.05）。LTCF 患者（73%）和医院获得性 CDAD 患者（69.8%）使用质子泵抑制剂（PPI）的频率高于社区获得性 CDAD 患者（43%）（p<0.05）。在 LTCF 患者（24.13%）和社区获得性 CDAD 患者（32.1%）中，有 24.13%和 32.1%的患者使用 PPI 没有明确的适应证，而医院获得性 CDAD 患者中仅有 12.9%的患者没有明确的适应证（p<0.05）。
这些观察结果表明，CDAD 主要起源于 LTCF（46.1%）和社区（33.3%）患者，而非住院患者（20.6%）。LTCF 患者仅有 15.2%的病例以腹泻为主要主诉。因此，如果 LTCF 患者出现腹痛、发热或精神状态改变等症状，同时伴有稀便，应怀疑 CDAD。大多数 LTCF 患者正在使用质子泵抑制剂（PPI），这是 CDAD 的一个危险因素，多达 24%的患者使用 PPI 没有明确的适应证。
