Original Study| Volume 11, ISSUE 4, P263-267, May 2010

Diarrhea, Clostridium difficile, and Intestinal Inflammation in Residents of a Long-Term Care Facility


      Long-term care facilities (LTCF) residents have been estimated to have the highest incidence of diarrheal illness among adults living in the developed world. This study describes undiagnosed diarrhea, intestinal inflammation, and Clostridium difficile colonization in a LTC population and explores whether these are associated with functional decline, as defined by weight loss or a change in cognitive or ADL status.


      An observational study of a convenience sampling of residents in a 180-bed LTCF was obtained; evaluation of stool and medical records was done. Stool specimens were evaluated for consistency, gross blood, inflammation (via quantitative fecal lactoferrin, IBD-SCAN), and C difficile (via PCR for gdh). SPSS and STATA were used and significance was set at P < .05.


      There were 46 stools collected; 13 of the subjects were male, 28 were older than 65 years, and 35 were prescribed 5 to 15 medications. Twenty-six of the 46 stools collected had elevated quantitative fecal lactoferrin levels. Although only 5 subjects were reported to have diarrhea (4 with elevated lactoferrin), 28 stool specimens were observed to be liquid or semi-solid (19 with elevated lactoferrin), and these liquid/ semisolid stools were significantly correlated with lactoferrin positivity (P = .017). In analysis of functional status, there was no statistically significant association between change in ADL (n = 17) or cognitive status (n = 5) and elevated lactoferrin. However, all 3 subjects who had significant weight loss had elevated lactoferrin, although the mean fecal lactoferrin was not statistically different from those without weight loss. Of the 2 samples with C difficile, both were liquid and, when compared with all other liquid stools (n = 22), the mean lactoferrin was statistically higher (134.1 versus 28.8 μg/mL, P = .008). These 2 subjects had neither weight loss nor change in cognitive status, but 1 had a change in ADL status.

      Discussion and conclusions

      Diarrhea in LTCF residents is underdiagnosed. Diarrhea and the presence of C difficile in the stool are associated with intestinal inflammation, as detected by fecal lactoferrin. With our small numbers, we were not able to identify a specific link; however, we were able to identify a correlation between weight loss and intestinal inflammation, but, with just 2 samples, not C difficile colonization. This relationship highlights the importance of larger studies to further examine the rate of diarrhea in LTCF; the effect of diarrhea and intestinal inflammation on weight loss; and the interaction of C difficile colonization with weight loss, malnutrition, and functional decline.


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        • Bennett R.G.
        • Greenough 3rd, W.B.
        Approach to acute diarrhea in the elderly.
        Gastroenterol Clin North Am. 1993; 22: 517-533
        • Lew J.F.
        • Glass R.I.
        • Gangarosa R.E.
        • et al.
        Diarrheal deaths in the United States, 1979 through 1987. A special problem for the elderly.
        JAMA. 1991; 265 (3281; 3283; 3284): 3280-3281
        • Simor A.E.
        • Bradley S.F.
        • Strausbaugh L.J.
        • et al.
        Clostridium difficile in long-term–care facilities for the elderly.
        Infect Control Hosp Epidemiol. 2002; 23: 696-703
        • Makris A.T.
        • Gelone S.
        Clostridium difficile in the long-term care setting.
        J Am Med Dir Assoc. 2007; 8: 290-299
        • Rao A.
        • Bradley S.
        Clostridium difficile in older adults and residents of long-term care facilities.
        Annals of Long-Term Care. 2003; 11: 42-47
        • Stubbs S.
        • Rupnik M.
        • Gibert M.
        • et al.
        Production of actin-specific ADP-ribosyltransferase (binary toxin) by strains of Clostridium difficile.
        FEMS Microbiol Lett. 2000; 186: 307-312
        • Terhes G.
        • Urban E.
        • Soki J.
        • et al.
        Community-acquired Clostridium difficile diarrhea caused by binary toxin, toxin A, and toxin B gene-positive isolates in Hungary.
        J Clin Microbiol. 2004; 42: 4316-4318
        • Warny M.
        • Pepin J.
        • Fang A.
        • et al.
        Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe.
        Lancet. 2005; 366: 1079-1084
        • Zilberberg M.D.
        Clostridium difficile–related hospitalizations among US adults.
        Emerg Infect Dis. 2006; 2009: 122-124
        • Redelings M.D.
        • Sorvillo F.
        • Mascola L.
        Increase in Clostridium difficile–related mortality rates, United States, 1999–2004.
        Emerg Infect Dis. 2007; 13: 1417-1419
        • Cefai C.
        • Elliot T.S.
        • Woodhouse K.W.
        Gastrointestinal carriage rate of Clostridium difficile in elderly, chronic care hospital patients.
        J Hosp Infect. 1988; 11: 335-339
        • Thomas D.
        • Bennett R.
        • Laughon B.
        • et al.
        Postantibiotic colonization with Clostridium difficile in nursing home patients.
        J Am Geriatr Soc. 1990; 38: 415-420
        • Simor A.E.
        • Yake S.L.
        • Tsimidis K.
        Infection due to Clostridium difficile among elderly residents of a long-term-care facility.
        Clin Infect Dis. 1993; 17: 672-678
        • Monsieur I.
        • Mets T.
        • Lauwers S.
        • et al.
        Clostridium difficile infection in a geriatric ward.
        Arch Gerontol Geriatr. 1991; 13: 255-261
        • Walker K.J.
        • Gilliland S.S.
        • Vance-Bryan K.
        • et al.
        Clostridium difficile colonization in residents of long-term care facilities: Prevalence and risk factors.
        J Am Geriatr Soc. 1993; 41: 940-946
        • Fulton J.D.
        • Fallon R.J.
        Is Clostridium difficile endemic in chronic-care facilities?.
        Lancet. 1987; 2: 393-394
        • Campbell R.R.
        • Beere D.
        • Wilcock G.K.
        • Brown E.M.
        Clostridium difficile in acute and long-stay elderly patients.
        Age Ageing. 1988; 17: 333-336
        • Corrado O.J.
        • Mascie-Taylor B.H.
        • Hall M.J.
        • Bolton R.P.
        Prevalence of Clostridium difficile on a mixed-function ward for the elderly.
        J Hosp Infect. 1990; 21: 287-292
        • Bentley D.W.
        Clostridium difficile-associated disease in long-term care facilities.
        Infect Control Hosp Epidemiol. 1990; 11: 434-438
        • Larson E.
        • Bobo L.
        • Bennett R.
        • et al.
        Lack of care giver hand contamination with endemic bacterial pathogens in a nursing home.
        Am J Infect Control. 1992; 20: 11-15
        • Rybolt A.H.
        • Bennett R.G.
        • Laughon B.
        • et al.
        Protein-losing enteropathy associated with Clostridium difficile infection.
        Lancet. 1989; 1: 1353-1355
      1. Minimum Data Set (MDS)- Version 2.0 For Nursing Home Resident Assessment and Care Screening. CMS, September 2000.

        • Gangarosa R.
        • Glass R.
        • Lew J.
        • Boring J.
        Hospitalizations involving gastroenteritis in the United States, 1985: The special burden of the disease among the elderly.
        Am J Epidemiol. 1992; 135: 281-290
        • Morley J.E.
        • Steinberg K.E.
        Diarrhea in long-term care: A messy problem.
        J Am Med Dir Assoc. 2009; 10: 213-217