Clinical Predictors of Severe Complicated Clostridium Difficile Infection

Abstract

Purpose:Clostridium Difficile infection (CDI) can be severe, and associated with complications and mortality. Treatment recommendations are stratified based on severity. However, there are no robust models to predict severe complicated CDI. The objective of this study was to create a clinically useful model to predict severe complicated CDI. Methods: The microbiology laboratory database and patient medical records were queried to identify cases of CDI from June 1, 2007 - May 31, 2010. Severe complicated CDI was defined as need for ICU admission or colectomy, or death within 30 days of CDI diagnosis. Variables including patient demographics, Charlson Co-morbidity index, temperature, peripheral leukocyte count, serum albumin, and change in serum creatinine were obtained. Univariate and multiple variable logistic regression models were used to assess the association of these variables with complications of CDI. Only patients who had data for each variable of interest were included in the multiple variable analyses. Results: The cohort included 1400 patients with CDI (50% female, median age at CDI diagnosis was 63.1 years [range 1.2-100.1]), and 357 (25.5%) were severe complicated CDI cases. The frequency of ICU admission, colectomy, and death within 30 days of diagnosis was 19.3%, 2.3%, and 7.3%, respectively. In univariate analysis, increasing age (OR 1.15, 95% CI 1.08-1.23, p<0.0001), increasing peripheral leukocyte count (OR 1.05, 95% CI 1.03-1.06, p<0.0001), change in serum creatinine >1.5 fold (OR 2.61, 95% CI 2.04-3.34, p<0.0001), serum albumin (OR 0.48, 95% CI 0.35-0.66, p<0.0001), temperature (OR 1.36, 95% CI 1.35-1.59, p=0.0002), and Charlson Co-morbidity index (OR 1.09, 95% CI 1.03-1.15, p=0.001) were associated with severe complicated CDI. Serum albumin and temperature were not included in the multiple variable model due to missing data. In the multiple variable model (adjusting for referral distance), increasing age (OR 1.1, 95% CI 1.03-1.18, p=0.0072), increasing peripheral leukocyte count (OR 1.04, 95% CI 1.03-1.05, p<0.0001) and change in serum creatinine greater than 1.5-fold (OR 2.3, 95% CI 1.75-2.98, p<0.0001) were independent predictors of severe complicated CDI, but Charlson Comorbidity index score was not. Conclusion: Older age, higher peripheral leukocyte count, and rising serum creatinine independently predicted severe complicated CDI. Temperature and low serum albumin were also associated with severe complicated CDI by univariate analysis. An appreciation of these variables could be pivotal in identifying patients at increased risk of CDI complications. It is conceivable that early aggressive monitoring and intervention in these patients could have beneficial effects.