Factors Predicting Severity in Clostridium difficile Infection

Abstract

Purpose: The incidence of Clostridium difficile Associated Diarrhea (CDAD) continues to rise; especially among inpatient, elderly, institutionalized, & debilitated populations. RUWA scoring system, a model developed to predict severity of CDAD, has been an important stepping stone in predicting severity. However, to date, no study has established a sufficiently accurate model applicable in community hospitals. The aim of the study is to identify factors predictive of severity & mortality in CDAD in community hospitals. Methods: Charts of 499 patients in 3 community hospitals, diagnosed with CDAD from Jan 2007 to Dec 2008 were retrospectively reviewed. Data was collected on patient factors such as chronic heart, lung, and kidney disease, diabetes, demographics, institutionalization, albumin, creatinine, PMNs, and WBCs. Severe disease was defined as pancolitis or megacolon on CT, mortality, and need for ICU admission. Results: The patients had a mean age of 72.5 years with a standard deviation of 16.42 years. In the study group, 62.12 were female, 50.5% were institutionalized, 72.7% had chronic disease, 11.62% required ICU care, and inpatient mortality was 11.42%. Low albumin (95.5% died vs. 58.3% lived, p=<0.001) and elevated PMNs (89.1% vs. 76.1% p=0.059) were more frequent in CDAD patients who died. Chronic disease was significantly more prevalent in those with CDAD who died during hospitalization compared with those who lived (86% vs. 71%, p=0.017). In our preliminary analysis, we did not find a significant association between institutionalization and CDAD mortality. Chronic disease was less frequent among patients who developed pancolitis or megacolon on CT compared with those who did not have such CT findings (63.7% vs. 75.1%, p=.025). Neither age nor albumin level were significantly related to CT finding of pancolitis or megacolon. Age, albumin, chronic disease, creatinine & PMNs were not significantly associated with the need for ICU admission. History of IBD, surgery, CDAD & subtotal colectomy were not analyzed due to their infrequent occurrence in our population. Conclusion: Mortality of hospitalized patients with C. difficile appear to be related to chronic disease, low albumin, and elevated PMNs. Whereas, institutionalization, age, gender, creatinine, and CT findings are not related to severity. Our study along with the RUWA model form the basis for a future prospective, multicenter trial which would help develop a reproducible model for predicting severity in CDAD in tertiary and community hospitals.