Toxigenic Clostridium difficile Lower Than VRE in Long-Term Care


Patients receiving long-term care more likely to test positive for VRE than toxigenic C. difficile.

hiv, vre, clostridium difficile, long term care

In patients receiving care in long-term care facilities, the rates of carbapenem-resistant Enterobacteriaceae (CRE), carbapenemase-producing Enterobacteriaceae (CPE), and toxigenic Clostridium difficile (C. difficile) colonization are lower than that of vancomycin-resistant enterococci (VRE), according to study findings in Hospital Infection.

“A stay in a long-term care facility is a risk factor for infection with multidrug-resistant organisms and toxigenic C. difficile because of age-associated morbidities and frequent referrals to and from acute-care hospitals,” Hong Bin Kim, MD, of Seoul National University, told MD Magazine. “We observed a low rate of colonization with CRE among patients from long-term care facilities at the time of hospital admission, and no CPE were identified using our screening method of culture in MHB with meropenem.”

In this single-center, active surveillance study, investigators obtained 2 rectal specimens from 282 patients receiving care in a 1328-bed tertiary hospital for more than 1 week. Specimens were collected within 2 days of admission to the hospital and were analyzed to determine status of CPE, VRE and toxigenic C. difficile colonization in these patients receiving long-term care.

A large majority of enrolled patients presented with cerebrovascular disease (66%), whereas most patients (86.2%) were confined to bed >50% of the time they were receiving care. A total of 81 patients had used antibiotics within a 3-month period of hospital admission.

Colonization of ≥1 CRE, VRE or toxigenic C. difficile occurred in 93 patients, whereas 7 patients possessed >1 organism. Approximately 1.4% of patients had detectable CRE, none of which produced carbapenemase, and these CRE isolates included Klebsiella pneumoniae (n= 3) and Escherichia coli (n= 1). A greater proportion of patients harbored VRE (20.9%), of which only 2 had data on previous colonization. No outbreaks occurred throughout the study, despite investigators taking contact precautions in only 2 patients. Additionally, only 7.1% of patients tested positive for toxigenic C. difficile, with 17 being asymptomatic.

Patients with antibiotic exposure within a 1-month and 3-month period of hospital admission were significantly more likely to harbor multidrug-resistant organisms (P =.01 and P =.03, respectively), possibly indicating that recent exposure to antibiotics could act as a risk stratification factor that can be implemented into a targeted screening strategy.

The investigators of the study were unable to assess the role of asymptomatic carriers as reservoirs for CDI in transmitting C. difficile. Additionally, the investigators did not evaluate whether targeted therapy would reduce CDI in this patient population, which potentially limits the clinical utility of the findings.

“The low prevalence of CRE carriage (and no CPE) in this study indicates that screening all admissions from long-term care facilities for CPE would not currently be a cost-effective infection control measure,” Kim concluded. “For screening to be justified, evidence would be needed that VRE carriers are an infection control risk in [the] hospital.”


Hwang JH, Park JS, Lee E, et al. Active Surveillance for Carbapenem-resistant Enterobacteriaceae, Vancomycin-resistant Enterococci and Toxigenic Clostridium difficile among Patients transferred from Long-term Care Facilities in Korea [published online February 21, 2018]. J Hosp Infect. doi: 10.1016/j.jhin.2018.02.017.

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