Effect of Nutritional Status on Length of Hospital Stay in Patients With Clostridium difficile-Associated Diarrhea

Abstract

Introduction:Clostridium difficile associated diarrhea (CDAD) is one of the most common nosocomial infections in hospitals and long term care facilities. Low serum albumin and serum protein, which are surrogates of nutritional status, are associated with increased incidence of CDAD and worse outcomes in patients with CDAD. However, these measures are crude and non-specific and there are no studies to date which demonstrate a direct association between the nutritional status - as assessed by standardized, replicable criteria - with outcomes of patients with CDAD. We aim to show that an Aspen Nutritional Index (ASI) is a more valid and accurate instrument to measure underlying malnutrition in patients with CDAD. Methods: We performed a retrospective cross-sectional study from April 2013 to June 2014. Hospitalized patients ≥ 18 years of age were included and divided into two groups: study group (diarrhea with a positive assay for antigen and toxins for c. difficile) and a control group (patients with negative assay for antigen and toxin for c. difficile). Each group was then subdivided into a non-malnourished group and a malnourished group according to the ASI (based on the 2012 ASPEN guidelines). Demographic data, Charlson comorbidity index (CMI), nutritional assessment, and, length of stay (LOS) were studied for each patient. All-cause mortality was also recorded for secondary outcomes. The inclusion criteria, exclusion criteria and all definitions were defined prior to the study. Results: A total of 314 patients were included: 148 patients in the study group (89 malnourished and 59 non-malnourished) and 166 in the control group (132 malnourished and 34 non-malnourished). Malnourished patients with CDAD had the longest LOS compared to other groups (Table 1). Malnourished patients with CDAD compared to non-malnourished control patients had a significantly increased LOS, mean±S.E. LOS (16.73±1.69 versus 11.35±1.33 days) (p=0.014). In addition, malnourished patients with CDAD had the highest all-cause mortality compared to the other groups (Table 2). All-cause mortality rate of malnourished patients with CDAD compared to non-malnourished control patients was 24.7% versus 5.9% (p=0.021). Mean CMI was 7±1 for all groups.Table 1: Mean length of stay between groups(in days)Table 2: Percentage all-cause mortalityConclusion: Malnourishment leads to prolonged LOS and increases all-cause mortality in CDAD. The ASI is the most accurate measure of underlying nutritional status and should be calculated in all patients with, or at risk for CDAD.