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The determinants of C. difficile infection in long-term care facilities: a portrait of patient- and facility-level factors across 90 care regions in the veterans affairs health care system

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Clostridium difficile infection (CDI) is an infectious diarrheal disease that is associated with antibiotic and healthcare exposures. Although individual-level risk factors have been extensively studied, the facility-level factors that drive CDI have not.


To study the determinants of CDI incidence across long term care (LTC) facilities, with a specific interest in the role importation of infectious patients from acute care (AC) facilities.


We conducted a retrospective cohort study of CDI from 2006 through 2012 across Veterans Affairs local healthcare systems (HCS) where both AC and LTC patient censuses were above an average of 10 patients per day. Our outcome was LTC-onset C. difficile lab-identified event, defined as a case with onset ≥ 3 days after admission occurring at least 8 weeks from a previous positive test.


We identified 90 local HCS that met our inclusion criteria. The incidence of C. difficile infection in LTC facilities was 3.6 per 10,000 patient-days. In bivariate weighted linear regression analyses, the most important predictors of facility CDI incidence were importation (R2=0.63, p<0.001) and antibiotic prescribing (R2=0.58, p<0.001). Time-series analyses revealed that increases in C. difficile case importation from AC facilities preceded increases in CDI rates for a period of up to 8 weeks. Multi-level analyses, that included individual-level covariates, revealed that C. difficile importation and facility-level antibiotic use acted independently of resident age, direct antibiotic exposure and direct proton pump inhibitor use.


This is the first study showing that importation of C. difficile cases from AC facilities and facility-level antibiotic use are principal drivers of CDI in LTC facilities. A regional approach, addressing rates in AC facilities, is needed to control CDI in LTC facilities.

Disclosure of interest

None declared.

Author information

Correspondence to KA Brown.

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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  • Veteran Affair
  • Long Term Care
  • Clostridium Difficile Infection
  • Clostridium Difficile
  • Long Term Care Facility