Increased Severity of Clostridium difficile Infection (CDI) Is Associated With Increased Mortality in Hospitalized Patients: A Single-Center Retrospective Cohort Study

Abstract

Introduction: CDI is associated with significant morbidity and mortality in hospitalized patients. We studied whether severity according to the Infectious Diseases Society of America (IDSA) 2010 guidelines had any effect on hospital based outcomes. Furthermore, we investigated whether adherence to these guidelines with respect to treatment had any effect on the same outcomes. Methods: Setting: Single-center retrospective cohort study conducted at an acute care facility for the period of April 1, 2012 to December 31, 2014.t Patients: Hospitalized adults with diarrhea that tested positive for CDI by polymerase chain reaction (PCR) assay, identified through the infection control committee's database. Exclusion criteria: Initiation of CDI therapy before hospitalization; lack of treatment for CDI; diagnosis and discharge from the emergency room; patients treated with intravenous metronidazole before diagnosis for non-CDI indications; and incomplete data. Definitions: Severity was categorized by IDSA guidelines. CDI treatment was classified as guideline adherent if treatment provided was with the correct antibiotic(s), route(s), and dosage(s). Non-adherence was defined as any of the following: incorrect antibiotic(s), route(s), and/or dosage(s). Primary outcomes: All cause in-hospital mortality. Secondary outcomes: Hospital length of stay (LOS) and intensive care unit (ICU) LOS Statistical Analysis: Multivariable logistic and linear regression analyses (SPSS Version 19) Results: 341 cases were identified, 53 were excluded, and 288 were analyzed. Severity of CDI was associated with increased mortality, hospital LOS and ICU LOS on univariate and multivariate analysis. Adherence to guidelines was observed in 43% of cases. Non-adherence was more common in the severe uncomplicated and complicated cases. On univariate analysis, adherence was associated with a trend towards reduced mortality (11% vs 6%, p = 0.1) and ICU LOS (2.2 vs 1.3 days, p = 0.1), and a significant reduction in hospital LOS (7.2 vs 5.4 days, p = 0.04). This did not reach significance on multivariate analysis. Conclusion: In our cohort, severe cases of CDI were associated with worse hospital outcomes. We showed that adherence to treatment guidelines improved these outcomes, but the adherence rate was less in the more severe cases. Our data suggest that implementation of the guidelines in severe cases of CDI could reduce mortality and LOS.Table 1: Severity of CDI (IDSA) and OutcomesTable 2: Outcomes for Adherence to IDSA Guidelines