Liver Cirrhosis Is Associated with Lower Hospital Costs and Length of Stay in Clostridium Difficile Infection, but Higher Mortality Risk: A Nationwide Outcome Analysis

Abstract

Introduction: Liver cirrhosis predisposes to worse outcomes on different clinical scenarios. Despite some studies have suggested increased Clostridium difficile infection (CDI) mortality in patients with liver cirrhosis, data is still inconsistent. The objective of our study was to determine if there are any differences in the outcomes in CDI cirrhotic versus non-cirrhotic patients. Methods: A retrospective cohort study was done using the United States 2013 National Inpatient Sample, the largest publically available inpatient database in the US. All patients with ICD-9 CM codes for a diagnosis of CDI were included. No exclusion criteria were used. We considered in-hospital mortality as primary outcome. Secondary outcomes were morbidity measured by intensive care unit (ICU) admission, shock, multi-organ dysfunction (MOD) and malnutrition; resource utilization measured by abdominal ultrasound (US), abdominal CT scan (ACT), length of hospital stay (LOS), total parenteral nutrition (TPN) use and total hospitalization charges. Patients were classified as having liver cirrhosis or no liver cirrhosis diagnosis based on ICD-9 CM codes. Odds ratios and means were calculated using multivariate regression analysis, after being adjusted for age, sex, race, Charlson Comorbidity Index, median income in the patient's zip code, hospital region, rural location, size and teaching status. Results: A total of 357,845 patients with CDI were included. 13,205 (3.6%) had a diagnosis of liver cirrhosis. Mean age was 65 years and 58% were female. Mortality rate was 7% overall, 10.3% in cirrhotics and 6.9% in non-cirrhotics. Adjusted odds ratios, means and p values are shown in Table 1. On multivariate analysis, patients with liver cirrhosis had higher mortality rates (OR 1.39; 95% CI 1.20-1.62, p= < 0.01) compared to non-cirrhotics. Regarding morbidity, malnutrition was more common in the cirrhotic group, but there were no other morbidity differences. For resource utilization, total charges, TPN use and LOS were lower in the cirrhosis group; US use was higher in patients with cirrhosis; ACT use was the same in both groups.Table 1: Adjusted Odds Ratios, Means and p-values for variables evaluated in patients diagnosed with Clostridium difficile infection with liver cirrhosis versus without liver cirrhosisConclusion: Liver cirrhosis in patients with CDI was associated with increased mortality risk, as well as higher odds for malnutrition. However, total hospitalization charges, LOS and TPN use were lower in cirrhotic patients with CDI. This findings could be explained by increased mortality rates with subsequent lower healthcare system use, but further studies are needed.