Clostridium Difficile Infection Is Associated with Persistent Increased Mortality in Patients with Ulcerative Colitis: Results of a Nationwide Analysis

Abstract

Introduction:Clostridium difficile infection (CDI) has been associated with worse outcomes in patients with ulcerative colitis (UC): from increased resource utilization to increased mortality. No study has addressed the impact of a previous CDI on outcomes among UC patients. Therefore, the aim of this study was to explore the current magnitude of the impact that previous or currnet episode of CDI has on UC. Methods: This was a retrospective cohort study using the 2013 National Inpatient Sample, the largest publically available inpatient database in the US. All patients with a principal ICD-9 CM diagnosis code for UC were included. There were no exclusion criteria. The primary outcome was in-hospital mortality. Secondary outcomes were morbidity measured by need for colectomy, intensive care unit (ICU) admission, shock and multi-organ failure; resource utilization measured by colonoscopy, abdominal CT scan, abdominal ultrasound (US), total parenteral nutrition (TPN), length of hospital stay (LOS) and total hospitalization charges. Patients were classified as having CDI and being CDI-free using ICD-9 CM codes. Using multivariate regression analysis, odds ratios and means were adjusted for age, sex, race, median income in the patient's zip code, Charlson Comorbidity Index, hospital region, urban location, size and teaching status. Results: 37,610 patients with UC were included, 1,675 (4.5%) of whom had CDI. Mean age was 45 years and 52% were female. The in-hospital mortality rate was 0.5% (3% in the CDI subgroup). Table 1 shows all adjusted odds ratios, means and p-values. On multivariate analysis, patients with CDI had higher mortality (OR:7.81, 95%CI:3.14-19.39, p < 0.01) compared to CDI-free patients. Looking at morbidity, patients with CDI had significantly increased odds of shock, ICU admission, and multi-organ failure. Colectomy rates did not significantly differ among the two groups. Both groups did not differ in abdominal CT, abdominal ultrasound or colonoscopy use. Further, total charges and LOS were significantly higher in patients with CDI.Table 1: Adjusted Odds Ratios, Means and p-values for the evaluated parameters for patients diagnosed with UC that had CDI versus no CDI.Conclusion: A previous or current episode of CDI is associated with increased mortality among patients with UC. This rate has been increasing over the past decade. Furthermore, CDI is associated with worse disease course as measured by rates of ICU admission, shock and multi-organ failure. CDI also has a direct negative impact on resource utilization, as measured by increased odds of abdominal CT use, LOS and total hospitalization charges.