Asymptomatic Carriers of Toxigenic C. difficile in Long-Term Care Facilities: A Meta-Analysis of Prevalence and Risk Factors

Abstract

BackgroundThe impact of Clostridium difficile colonization in C. difficile infection (CDI) is inadequately explored. As a result, asymptomatic carriage is not considered in the development of infection control policies and the burden of carrier state in long-term care facilities (LTCFs) is unknown.PurposeTo explore the epidemiology of C. difficile colonization in LTCFs, identify predisposing factors and describe its impact on healthcare management.Data SourcesPubMed, Embase and Web of Science (up to June 2014) without language restriction, complemented by reference lists of eligible studies.Study SelectionAll studies providing extractable data on the prevalence of toxigenic C. difficile colonization among asymptomatic residents in LTCFs.Data ExtractionTwo authors extracted data independently.Statistical MethodsThe pooled colonization estimates were calculated using the double arcsine methodology and reported along with their 95% random-effects confidence intervals (CIs), using DerSimonian-Laird weights. We assessed the impact of patient-level covariates on the risk of colonization and effects were reported as odds ratios (OR, 95% CI). We used the colonization estimates to simulate the effective reproduction number R through a Monte Carlo technique.ResultsBased on data from 9 eligible studies that met the specified criteria and included 1,371 subjects, we found that 14.8% (95%CI 7.6%-24.0%) of LTCF residents are asymptomatic carriers of toxigenic C. difficile. Colonization estimates were significantly higher in facilities with prior CDI outbreak (30.1% vs. 6.5%, p = 0.01). Patient history of CDI (OR 6.07; 95% CI 2.06–17.88; effect derived from 3 studies), prior hospitalization (OR 2.11; 95% CI 1.08–4.13; derived from 3 studies) and antimicrobial use within previous 3 months (OR 3.68; 95% CI 2.04–6.62; derived from 4 studies) were associated with colonization. The predicted colonization rate at admission was 8.9%.ConclusionAsymptomatic carriage of toxigenic C. difficile represents a significant burden in LTCFs and is associated with prior CDI outbreaks in the facility, a history of CDI, prior hospitalization and antimicrobial use. These findings can impact infection control measures at LTCFs.

Asymptomatic and yet C. difficile-toxin positive? Prevalence and risk factors of carriers of toxigenic Clostridium difficile among geriatric in-patients

“…Additionally, the number of previous hospital stays within the past 6 months raised the probability of a positive CD-PCR by factor 1.6 each (95% CI: 1.1–2.2). This corresponds to previous studies which also determined previous episodes of CDI and treatment with antibiotics as the highest risk factors for a toxigenic CD colonization [34, 35]. …”

Nosocomial Clostridium difficile Infection among Patients Over 90 Years Old

“…Antibiotic stewardship programs (ASP) have shown a significant protective effect (pooled risk ratio 0.48; 95% CI 0.38-0.62) on CDI in recent meta-analyses [8,9]. Therefore, strengthening ASP and promoting strict infection control can reduce the incidence of CDI in the elderly population in NHs and LTCF.…”

Control of Clostridium difficile Infection by Defined Microbial Communities

“…Patients in Long-Term Care Facilities have a higher average asymptomatic carriage rate at 14.8% (95% CI 7.6% - 24.0%), though it is hard to discern if this is due to a change in the cohort physiology (microbiota, immune response), the environment, or both (58). Asymptomatic carriage is often limited in duration (reviewed in (56)) and has been associated with a lower likelihood of developing symptomatic CDI (59, 60).…”