• Fredrick M Abrahamian, David A Talan, Anusha Krishnadasan, Diane M Citron, Ashley L Paulick, Lydia J Anderson, Goldstein Ellie J C EJC David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA; R. M. Alden Research Laboratory, Culver City, CA., Gregory J Moran, and EMERGEncy ID NET Study Group.
• Department of Emergency Medicine, Olive View-University of California, Los Angeles Medical Center, Sylmar, CA; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA. Electronic address: fmasjc@ucla.edu.
• Ann Emerg Med. 2017 Jul 1; 70 (1): 19-27.e4.

Study ObjectiveThe incidence of Clostridium difficile infection has increased and has been observed among persons from the community who have not been exposed to antibiotics or health care settings. Our aims are to determine prevalence of C difficile infection among emergency department (ED) patients with diarrhea and the prevalence among patients without traditional risk factors.MethodsWe conducted a prospective observational study of patients aged 2 years or older with diarrhea (≥3 episodes/24 hours) and no vomiting in 10 US EDs (2010 to 2013). We confirmed C difficile infection by positive stool culture result and toxin assay. C difficile infection risk factors were antibiotic use or overnight health care stay in the previous 3 months or previous C difficile infection. We typed strains with pulsed-field gel electrophoresis.ResultsOf 422 participants, median age was 46 years (range 2 to 94 years), with median illness duration of 3.0 days and 43.4% having greater than or equal to 10 episodes of diarrhea during the previous 24 hours. At least one risk factor for C difficile infection was present in 40.8% of participants; 25.9% were receiving antibiotics, 26.9% had health care stay within the previous 3 months, and 3.3% had previous C difficile infection. Forty-three participants (10.2%) had C difficile infection; among these, 24 (55.8%) received antibiotics and 19 (44.2%) had health care exposure; 17 of 43 (39.5%) lacked any risk factor. Among participants without risk factors, C difficile infection prevalence was 6.9%. The most commonly identified North American pulsed-field gel electrophoresis (NAP) strains were NAP type 1 (23.3%) and NAP type 4 (16.3%).ConclusionAmong mostly adults presenting to US EDs with diarrhea and no vomiting, C difficile infection accounted for approximately 10%. More than one third of patients with C difficile infection lacked traditional risk factors for the disease. Among participants without traditional risk factors, prevalence of C difficile infection was approximately 7%.Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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