Risk factors associated with hospital-origin vs. community-origin Clostridium difficile-associated diarrhea

Purpose: The incidence of community-origin Clostridium difficile-associated diarrhea (CO-CDAD) is increasing.  Little is known about how risk factors differ between patients with CO-CDAD vs. hospital-origin (HO)-CDAD. 

Methods: A retrospective analysis (4/05-6/11) of the Health Facts® database (Cerner Corp., Kansas City, MO), containing comprehensive clinical records from 186 US hospitals, identified hospitalized patients ≥18 years with a first positive C. difficile toxin collected <48 hours prior to (CO-CDAD) or  ≥48 hours after (HO-CDAD) admission. A multilevel mixed-effects logistic regression model was constructed; variables that were collected at baseline or soon after admission were considered. Adjusted odds ratios (ORs) predicting HO-CDAD vs. CO-CDAD (referent) were reported.

Results: A total of 4,521 patients with HO-CDAD and 2,851 with CO-CDAD met inclusion criteria.  HO-CDAD patients were at a greater risk for heart failure (OR 1.48, P<0.001), diabetes (OR 1.15, P=0.019), and critical care use within 48 hours of admission (OR 2.06, P<0.001).  In contrast, renal impairment (OR 0.655, P<0.001) and inflammatory bowel disease (IBD) (OR 0.445, P<0.001) were each associated with CO-CDAD.  Cancer patients were equally as likely to contract HO as CO-CDAD.  Age did not differ between groups, but HO-CDAD patients were more likely to be male and of black race. The model had acceptable discriminatory power evidenced by an area under the ROC curve of 0.718; 95% CI (0.706, 0.730).  

Conclusion: CO and HO-CDAD patients present with different comorbidities and demographics.  HO-CDAD patients are more likely to have critical care exposure shortly after admission, which may increase their risk of developing CDAD in the hospital.  Conversely, patients having underlying conditions such as renal disease and IBD may be at greater risk for hospitalization with CO-CDAD.