Adherence to Treatment Guidelines for Clostridium difficile Infections in the Intensive Care Unit

Abstract

Introduction: The incidence of Clostridium difficile infections (CDI) in intensive care unit (ICU) patients is about 4%. Several studies have looked at patient outcomes based on adherence to SHEA-IDSA guidelines for treatment of CDI in general patient populations. However, there is a paucity of data regarding the effect of these guidelines in an ICU population. The goal of this study is to assess the impact of guideline adherent therapy (GAT) vs. guideline non-adherent therapy (non-GAT) on outcomes of ICU patients diagnosed with CDI. We measured CDI cure, all-cause mortality, mortality from CDI, and hospital length of stay. Methods: In this retrospective study we reviewed 400 patients admitted to an ICU at a tertiary care center and diagnosed with CDI, between January 2010 and December 2016 (Figure 1). We extracted patient demographics, comorbidities, concomitant therapies, CDI severity, CDI antibiotic regimen, and clinical outcomes. Comparisons between GAT and non-GAT patients were made using Kruskal-Wallis and Fisher's exact tests as appropriate.FigureResults: 360 patients were included in the final analysis, of which only 58 (16.1%) received GAT. We did not find a significant difference in guideline adherence based on disease severity (Table 1). GAT cured 72.4% of patients with CDI vs 55.3% of patients treated with non-GAT (p=0.023).The GAT group had longer median hospital stays compared to the non-GAT group (32.5 [interquartile range 23.2 - 48.0] days vs. 27.0 [16.0 - 44.0] days respectively, p=0.028). We found no significant difference in CDI-related or all-cause mortality. Outcomes were also analyzed for undertreated vs. overtreated patients, within the non-GAT group (Table 2).Table: Table. Guideline adherence based on clinical stateTable: Table. Outcomes based on guideline adherence and overtreatment vs. undertreatmentConclusion: Patients who received GAT had a higher cure rate. However, the majority of critically ill patients in this study received non-GAT. Unlike prior studies in the general population, we did not observe a difference in mortality based on guideline adherence. Paradoxically, patients whom received GAT were hospitalized longer. Data for CDI treatment is stronger for the general patient population with mild or moderate disease than for critically ill patients. Despite current guidelines, ICU patients often require treatment decisions based on patient characteristics and expert experience. Future prospective studies are warranted to determine optimal antibiotic regimens for critically ill patients with CDI as well as factors contributing to divergence from current recommendations in this population.