MOVING OUTPATIENT Although predominantly associated with hospital inpatients, increasingly Clostridum difficile infections are originating from outpatient facilities.

Clostridium difficile infection may be as problematic in surgical centers and in other outpatient settings as it is in hospitals, a new study suggests.

The deadly bacteria has long been known to afflict hospital inpatients. Increasingly, however, C. difficile infections are being reported in the outpatient healthcare environment — surgical centers, emergency departments, hemodialysis centers, hospital-based outpatient settings and urgent care centers — according to research published in the journal Open Forum Infectious Diseases.

Surgical centers appear to be especially vulnerable. "C. difficile transmission might be more likely to occur" in outpatient settings where procedures are performed or there is long duration and high frequency of patient contact with healthcare providers and the environment, according to the study.

While C. difficile frequently occurs among older hospital inpatients taking antibiotics for other infections, so-called community-associated cases are increasing, climbing from 35% of the total U.S. cases in 2011 to 41% in 2014, the authors note.

It was no surprise that the study also confirmed that antibiotic use is a primary risk factor for community-associated C. difficile infection. It's well known that antibiotics kill both good and bad bacteria in the gut and let C. difficile grow freely in the intestinal tract and cause severe diarrhea.

"There's a lot of work that needs to be done in terms of improving outpatient prescribing practices and making sure that providers are appropriately prescribing antibiotics," says lead author Alice Guh, MD, MPH, a medical officer with the CDC's Division of Healthcare Quality Promotion.

The study matched 226 patients who tested positive for C. difficile after being treated as an outpatient or within 3 days of hospitalization with non-infected controls. A team of researchers conducted phone interviews with study participants to obtain information about their overall health, medication use, recent healthcare visits, household exposure to C. difficile and diet.

The findings revealed that 82% of patients with community-acquired C. difficile had received outpatient care and 62% had taken antibiotics. In comparison, 58% of non-infected individuals had been treated as outpatients and 10% had taken antibiotics.

Most patients in the study who reported antibiotic use received outpatient care for ear, sinus and respiratory infection and as prophylaxis before dental procedures. The researchers note that at least half of antibiotics prescribed for these indications are unnecessary. Only 4% of infected patients underwent outpatient surgery, according to the study. However, the researchers note that C. difficile transmission might be more likely to occur in outpatient care areas, including surgical centers, where procedures are performed or there is long duration and high frequency of patient contact with healthcare providers.

One infection prevention consultant says you should act now to improve your use of antibiotics before being required to do so. "There is talk that the federal government will eventually mandate that surgery centers develop antimicrobial stewardship programs," says Phenelle Segal, RN, CIC, president of Infection Control Consulting Services in Delray Beach, Fla. "The Joint Commission has already added an antimicrobial stewardship standard for hospitals, and that's expected to filter down to ASCs."

Infection preventionists should ensure that the use of pre-op antibiotics adheres to national guidelines, discuss with surgeons which antibiotics they're prescribing after surgery and make sure patients are using antibiotics appropriately after discharge, adds Ms. Segal.

"It's extremely important that antibiotics are given as recommended," says Ms. Segal. "Prescribing guidelines are written in accordance with studies that investigate what's best for patient care."

Daniel Cook