C diff infection among U.S. ED patients


Title: C. diff infection common in emergency department patients, even without risk factors.

Clinical Question: Should all emergency department (ED) patients with diarrhea, without vomiting, get tested for Clostridium difficile?

Background: C. difficile infection has been described in low-risk patients in retrospective studies, but the prevalence in a prospective cohort has not been evaluated.

Study Design: Prospective, observational study.

Setting: Ten urban, university-affiliated EDs in the United States between 2010 and 2013.

Synopsis: 422 patients met the inclusion of criteria of age older than 2, at least three diarrhea episodes in 24 hours, and absence of vomiting. The prevalence of C. difficile by stool culture and toxin assay was 10.2% (43/422; 95% CI, 7.7%-13.4%). The prevalence was 6.9% among patients without traditional risk factors defined as prior history of C. difficile, overnight health care stay, or antibiotic exposure in the last 3 months. The biggest limitation for this study is that the prevalence of C. difficile in the “low-risk” group may be overestimated given that factors such as use of antacids, history of inflammatory bowel disease, and immune suppression were not considered traditional risk factors. Also, 15 of the C. difficile samples were obtained via rectal swab, which is not standard of diagnosis.

Bottom Line: The absence of traditional risk factors does not exclude the presence of C. difficile infection, which should be considered in ED patients with diarrhea and no vomiting.

Citation: Abrahamian FM, Talan DA, Krishnadasan A, Citron DM, Paulick AL, Anderson LJ, et al. Clostridium difficile infection among U.S. emergency department patients with diarrhea and no vomiting. Ann Emerg Med. 2017; doi: 10.1016/j.annemergmed.2016.12.013.

Dr. Ayoubieh is assistant professor in the division of hospital medicine at the University of New Mexico.

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