Clostridium difficile infection among health care workers receiving antibiotic therapy.

Sir—Clostridium difficile is the most common cause of health care–associated infectious diarrhea in industrialized countries [1]. Disruption of normal barriers, such as gastric acidity and the indigenous microflora of the colon, facilitates colonization of the intestinal tract by C. difficile [2]. Host factors such as age, increased disease severity, and the ability to mount an antibody response to toxin A play an important role in determining whether colonized individuals develop infection [1]. Because the hands and clothing of health care workers frequently become contaminated with C. difficile, they may be at risk for occupationally acquired infection if they receive antibiotic therapy that disturbs the colonic microflora [2]. However, symptomatic C. difficile infections have rarely been reported among health care workers [3]. We previously reported a patient transporter from the University Hospitals of Cleveland who developed C. difficile–associated diarrhea and vancomycin-resistant Enterococcus colonization after receiving clindamycin therapy [3]. We report 4 additional cases of C. difficile infection among health care workers at 3 health care facilities in Cleveland, Ohio. Table 1 shows the demographic and clinical characteristics of the 4 health care workers. Three subjects were employees of our institutions, and 1 was referred from a local hospital. All were in good health with the exception of the conditions for which antibiotics were prescribed. Subject 1 received treatment with a proton pump inhibitor in addition to antibiotic therapy. All subjects developed diarrhea during antibiotic treatment or within 2 weeks after completing it. For each case, a stool immunoassay for C. difficile toxin had a positive result, and cultures for other bacterial enteric pathogens were negative. Three of the cases occurred within the past 2 years, during a period in which both hospitals were experiencing an increase in C. difficile infections among patients. Our report suggests that C. difficile may be an underappreciated occupational risk for health care workers. The cases illustrate that even healthy individuals receiving short courses of relatively narrow-spectrum antibiotics may be at risk for C. difficile infection. Many immunocompromised or chronically ill individuals are employed by health care facilities and may be at greater risk. In a survey conducted at the Louis Stokes Cleveland Veterans Affairs Medical Center, 45% of health care workers had received antibiotics within the past year (authors’ unpublished data). Carmeli et al. [4] likewise found that 47% of health care workers surveyed had received antibiotic treatment within the past year. We recommend that health care workers be educated about the potential risk of occupationally-acquired C. difficile infection associated with antibiotic therapy. Because family members may also be at risk [5], they should also receive education about C. difficile infection. Antibiotic therapy should be prescribed for health care workers only when necessary, and careful attention to hand hygiene should be indicated during and after antibiotic therapy.