Analysis of secular trends and impact of Clostridium difficile in hospitalized children with inflammatory bowel disease

Abstract

Children with inflammatory bowel disease (IBD) have been shown to have an increased risk of Clostridium difficile associated disease (CDAD). Little is known about the trend or the impact of CDAD disease in children with IBD. We sought to evaluate secular trends in hospitalization of IBD children with CDAD and to evaluate the impact of CDAD in hospitalized children with IBD. The Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUP-KID) is a nationwide United States pediatric inpatient database. The HCUP-KID was used to design a retrospective cohort study of hospitalized children with IBD. Years 1997, 2000, 2003, and 2006 were evaluated, and patients age 5-20 years old were included. Utilizing ICD-9 codes we identified patients with IBD and CDAD. The trends in hospital rates were calculated by dividing the HCUP-KID weighted cases by the national US Census Bureau estimates for the respective ages and years. Chi-squared test for trend was utilized to assess trend in CDAD, IBD, and colectomy. Wilcoxon rank sum test was used to compare length of stay (LOS) and charges. Charges were inflation adjusted to June 2009 dollars utilizing the Consumer Price Index for inpatient hospital services. HCUP-KID weighted values were utilized to generate national estimates and in analyses. Odd ratios were calculated utilizing logistic regression including covariates age and gender. The weighted national total sample was 8,162,120 with 48,113 identified with IBD and 1167 with IBD and CDAD. There is an increasing trend in the hospitalization rate for IBD with an annual relative percent increase (ARPI) of 13.4 (p<.0001) and an even higher trend for IBD with CDAD, with an ARPI of 26.0 (p<.0001). The absolute risk of hospital discharge with CDAD in children with IBD is 24.3/1000, with Crohn's disease (CD) 21.6/1000, with ulcerative colitis (UC) 49.0/1000, and 1.6/1000 for all other discharges. The odds ratios (95% CI) for discharge with diagnosis of CDAD with IBD is 15.8(14.9-16.8), CD 13.8(12.9-14.8) and UC 29.2(25.6-33.2). There were no deaths in children with IBD and CDAD. The ARPI for colectomy in IBD was 3.7 (p<.0001), however, among IBD children there was not a trend in colectomy rate associated with CDAD. The median (IQR) length of stay for patients with CDAD and IBD was 6 (4-12) vs. children with IBD only 4 (2-7) and was significantly different (p<.0001). The median (IQR) charges for IBD and CDAD were $27,499 ($14,110-$55,965) vs. IBD alone $18,008 ($9,756-$34,662) with a significant difference (p<.0001). There is an increasing rate of IBD children hospitalized with CDAD over the four time periods. There is a significant increase in length of stay and hospital charges for IBD children hospitalized with a diagnosis of CDAD. Hospitalized children with IBD are at an increased risk for CDAD and this risk is higher for patients with UC than with CD. The views expressed in this article are those of the author and do not reflect the official policy or position of the United States Air Force, Department of Defense, or the U.S. Government.