Impact Of Clostridium Difficile Infection Research Articles

The Impact of Clostridium difficile Infection in Contemporary Vascular Surgery

The Impact of Clostridium difficile Infection in Contemporary Vascular Surgery

Clostridium Difficile is associated with High Mortality among Cirrhotics in India

Background: To assess the prevalence and impact of Clostridium difficile infection (CDI) in hospitalized patients with cirrhosis in India.

Evaluating Risk Factors and Outcomes For Clostridium Difficile Infection (CDI) In Stem Cell Transplant (SCT) Recipients

IntroductionClostridium difficile infections (CDI) are the leading cause of infectious diarrhea among pts undergoing stem cell transplantation (SCT). Data from large pt samples evaluating the trends, risk factors, hospitalization outcomes are lacking. We have analyzed the Nationwide Inpt Sample (NIS) database to evaluate the trends in the incidence and the impact of CDI on hospitalization outcomes among SCT recipients. MethodsWe used the NIS database to obtain the hospitalization data for primary procedures of autologous and allogeneic SCT between 01/2001 until 12/2010. We performed separate multivariate logistic regression analyses to evaluate risk factors of CDI in SCT pts and hospitalization outcomes including length of stay (LOS), in-hospital mortality (IHM) and hospitalization charges. Comorbidites were identified using software that created measures reported by Elixhauser et al. ResultsThe incidence of CDI among transplant pts has remained relatively stable over time (Fig 1), with a higher cumulative incidence of CDI among recipients of allogeneic grafts (allogeneic vs. autologous SCT: 8.29% vs. 5.63%; p<0.001). There was an association between CDI and the presence of multiple comorbidities among autologous SCT pts (p=0.05), and a similar trend was seen in allogeneic transplant pts. Mean LOS (CDI vs. none: autologous 26 vs. 20 days, p<0.0001; allogeneic 42 vs 30 days, p<0.001; respectively), IHM (CDI vs. none: autologous, 4.0 vs. 2.2%, p=0.0003; allogeneic 12.7 vs 9.2%, p=0.0008) and mean hospitalization charges (CDI vs. none: autologous $208,025 vs. $145,250, p<0.0001; allogeneic $367,415 vs $270,366 p<0.0001; respectively) were significantly higher among SCT pts with CDI (Table 1). [Display omitted] Table 1Pt characteristics, multivariate regression models for evaluating risk and outcomes of SCT pts with CDIAutologous SCTAllogeneic SCTCDI (%) (N=3772)SCT patients (%) (N=63202)p-valueCDI (%) (N=3440)SCT patients (N=38066)p-valueMean age (SE)54.3 (0.52)52.02 (0.27)<0.000145.07 (0.64)46.57 (0.38)<0.0098Male2311 (61.3)37038 (58.6)0.15962188 (63.6)21906 (57.6)0.0005White2369 (77.4)26124 (74.3)0.10892199 (77.7)23695 (78)0.847Comorbidities ≥12945 (78)46872 (74.2)0.052607 (75.8)27712 (72.8)0.1073Medicare945 (25.1)12460 (19.8)<0.0001310 (9.0)4111 (10.8)0.183Medicaid330 (8.8)6818 (10.8)0.1161474 (13.8)3996 (10.5)0.0126Private Insurance2320 (61.6)40209 (63.8)0.24832486 (72.4)27601 (72.7)0.8798Mean LOS (SE)*26 (0.71)20 (0.27)<0.0001*42 (1.59)30 (0.68)<0.0001*IHM152 (4.0)1330 (2.1)0.0003438 (12.7)3360 (8.8)0.0008Charge Mean (SE)208025 (8370.6)145250 (4311.3)<0.0001*$367415 (15033)$270366 (11835)<0.0001*Multivariate logistic regression model evaluating risk of CDI in SCT patientsVariableOdds RatioRefp-valueOdds RatioRefp-value≥651.4 (0.987-1.985)Age <40 (Ref)0.19450.637 (0.426-0.953)0.0834Male1.25 (1.054-1.483)Female (Ref)0.01031.351 (1.157-1.576)Female (Ref)0.0001Medicare1.149 (0.878-1.502)Private (Ref)0.04390.85 (0.581-1.244)Private (Ref)0.4605Medicaid0.887 (0.642-1.226)0.76731.269 (0.920-1.749)0.0272No Comorbidities0.831 (0.650-1.063)Comorbidities ≥10.14060.829 (0.672-1.024)Comorbidities ≥10.082 ConclusionsThe incidence of CDI among both autologous and allogeneic SCTs have remained stable over the last decade, with a slightly higher risk among allogeneic SCT pts. CDI was associated with longer hospital stay, higher charges and higher IHM for both autologous and allogeneic transplant pts. While this analysis does not permit us to directly ascribe differences in outcome to CDI alone, these data suggest that CDI has a major morbid impact in the setting of SCT, and provides a rationale for development of more effective approaches for prevention of CDI in these pt populations. Disclosures:Kaufman:Onyx: Consultancy; Celgene: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Janssen: Consultancy; Millenium: Consultancy; Merck: Research Funding. Lonial:Millennium: Consultancy; Celgene: Consultancy; Novartis: Consultancy; BMS: Consultancy; Sanofi: Consultancy; Onyx: Consultancy.Multivariate logistic regression model evaluating hospitalization outcomes in SCT patients with CDI #CDIAbsencePresencep-valueCDIAbsencePresencep-valueLOS >19 days0.382 (0.31-0.466)1.00 (Ref)<0.0001LOS > 27 days0.337 (0.27-0.42)1.00 (Ref)<0.0001Charge > $125,0910.483 (0.40-0.58)<0.0001Charge > $22,60110.487 (0.38-0.67)<0.0001IHM0.68 (0.44-1.06)0.089IHM0.661 (0.50-0.87)0.0037SE: Standard error; *adjusted for age, race, sex, comorbidity and payer status.#Median LOS and charges used as cut-off for hospitalization outcomes

Impact of Clostridium difficile infection on pediatric appendicitis.

Clostridium difficile is an important cause of nosocomial infection in the pediatric population. The purpose of this study is to estimate the impact of Clostridium difficile infection complicating pediatric acute appendicitis. This study utilizes the combined 2009 and 2012 Kids' Inpatient Database. Statistical analysis is weighted and was done using Survey Sampling and Analysis procedures in SAS 9.4. We identified 176,934 cases with appendicitis and 0.2% (n = 358) had a concurrent diagnosis of C. difficile. The proportion of cases with C. difficile in perforated appendicitis was greater than in the non-perforated cases (0.39% vs. 0.06%; p < .01). Multivariate analysis showed that perforated appendicitis (OR 5.22), and anemia (OR 4.95) were independent predictors of C. difficile infection (p < .001). Adjusted for perforated appendicitis, cases with C. difficile had 4.78days longer length of stay (LOS) and higher total charges of $29,887 (all p < 0.0001) compared to non-C. difficile cases. C. difficile infection is a rare, but impactful complication of pediatric appendicitis and is associated with greater disease severity. Proper antibiotic stewardship could minimize the risk of C. difficile in pediatric appendicitis.

Clostridium difficile Infection Reservoirs Within an Acute Rehabilitation Environment.

Clostridium difficile infection is a common hospital-associated infection spread via patient contact or contaminated environments. The risk for spread of C difficile may be greater in inpatient rehabilitation units than in some hospital units as patients are not confined to their rooms and often share equipment. Environmental disinfection is challenging in shared medical equipment, especially in equipment with complex designs. The study aimed to examine the presence of C difficile spores within an acute rehabilitation environment and to evaluate disinfection effectiveness. Cultures were performed on 28 rehabilitation rooms, 28 rehabilitation floor surfaces, and 80 shared devices and equipment. Two disinfection interventions were implemented, and environmental cultures then were repeated postintervention. Environmental cultures positive for CD spores were rehabilitation rooms (1/28), rehabilitation floors (13/28), and wheelchairs (3/20). After the implementation of new disinfection methods, repeat cultures were obtained and produced negative results. Nonsporicidal disinfectant was not effective on hospital floors. Sporicidal disinfection of the floor is important when rates of C difficile infection are increased. Wheelchairs are complex devices and difficult to properly clean. The hospital purchased an ultraviolent device for wheelchair cleaning with a subsequent reduction in spores on repeat cultures. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. Upon completion of this article, the reader should be able to: (1) Recognize the impact of Clostridium difficile infections on the healthcare system; (2) Describe potential reservoirs of Clostridium difficile in the inpatient rehabilitation environment; and (3) Discuss interventions that may be implemented to reduce the reservoirs of Clostridium difficile on the rehabilitation unit. Advanced. The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The Impact of Clostridium Difficile Infections on In-Hospital Outcomes of Venous Thromboembolism (Deep Vein Thrombosis or Pulmonary Embolism) Hospitalizations.

BackgroundClostridium difficile infection (CDI) is associated with high mortality. Studies have shown an increased rate of venous thromboembolism (VTE) in patients with CDI. However, literature regarding the impact of CDI on outcomes of VTE-related hospitalizations is scarce. Our study aimed to assess the impact of CDI on in-hospital outcomes among VTE hospitalizations.MethodsThe 2016 National Inpatient Sample (NIS) was used to identify all adult hospitalizations in the United States with a primary discharge diagnosis of acute VTE. Hospitalizations with deep vein thrombosis (DVT) or pulmonary embolism (PE) were included under VTE. The sample was stratified based on the presence or absence of active CDI. Chi-square test and weighted Student’s t-test were used to analyze categorical and continuous variables, respectively. The adjusted odds ratio (OR) for clinical outcomes were calculated using multivariate logistic regression analysis. Subgroup analyses for DVT and PE hospitalizations were performed. All analyses were completed in SAS (SAS Institute Inc., Cary, NC), and a p-value of <0.05 was considered statistically significant.ResultsWe identified 382,585 weighted hospitalizations for VTE. Among them, 0.8% had concomitant CDI. The presence of CDI was associated with a statistically significant increase in in-hospital mortality (6% vs. 3%), hospitalization cost ($147,356.5 vs. $55,193), and length of stay (13.7 vs. 5.4 days). There were more incidents of bleeding and acute respiratory failure requiring prolonged ventilation in patients with CDI. The odds of stroke were significantly higher in patients with CDI and DVT.ConclusionCDI independently increased in-hospital mortality in VTE. Preventing CDI in the VTE population may mitigate complications, improve in-hospital outcomes, and reduce treatment costs.

Applying a mixed methods design to test saturation for qualitative data in health outcomes research.

Saturation, a core concept in qualitative research, suggests when data collection might end. It is reached when no new relevant information emerges with additional interviews. The aim of this research was to explore whether a mixed methods design could contribute to the demonstration of saturation. Firstly, saturation was conceptualized mathematically using set theory. Secondly, a conversion mixed design was conducted: a set of codes derived from qualitative interviews were quantitized and analyzed using partial least squares (PLS) regression to document whether saturation was reached. A qualitative study conducted by other researchers prior to this work (i.e. none of the present authors was involved in this study) was used to test saturation using PLS regression. This illustrative qualitative study aimed to investigate the impact of Clostridium difficile infection (CDI) on nurses’ work in the hospital and the results were published elsewhere (Guillemin et al. 2015). Semi-structured interviews were conducted with 12 nurses. Saturation was characterized by the cumulative percentage of variability accounted for by PLS factors. After 12 interviews, this percentage was 51% which suggests that saturation was achieved at least on main themes. Two main themes identifying similarities in the experience of nurses caring for patients with CDI were identified: Organization/Coordination of the working day and Time-consuming work. Although dependent on the coding of qualitative data, PLS regression of quantitized data from qualitative interviews generated useful information for the determination of saturation.

Incidence, Predictors, and Impact of Clostridium difficile Infection on Cardiac Surgery Outcomes

Clostridium difficile infection (CDI) has been associated with morbidity and mortality after cardiac operations. The present study examined incidence, predictors, and impact of CDI on inpatient mortality and resource utilization. An analysis of adult patients undergoing elective coronary artery bypass grafting or valvular operations from 2005 to 2016 was performed using the National Inpatient Sample. Trends in CDI were assessed using a modified Cochran-Armitage analysis. Multivariable multilevel regressions were used to identify predictors of CDI, and propensity-matched pairs were generated using Mahalanobis 1-to-1 matching to compare mortality, length of stay, and costs of CDI patients with the non-CDI cohort. The overall rate of CDI for an estimated 2,026,267 patients who underwent elective major cardiac surgery was 0.5% with no change in incidence (P for trend= .99). Predictors of CDI included advanced age (≥65 y; adjusted odds ratio [AOR], 1.88; 95% confidence interval [CI], 1.58-2.24), female gender (AOR, 1.29; 95% CI, 1.15-1.44), heart failure (AOR, 1.57; 95% CI, 1.40-1.76), and combined coronary artery bypass grafting/valve operations (AOR, 1.60; 95% CI, 1.24-2.08). Neither region nor bed size was associated with CDI. In contrast CDI mortality was lower at teaching hospitals compared with rural hospitals. Among matched pairs CDI was independently associated with higher mortality, length of stay, and Gross Domestic Product-adjusted costs. CDI occurs in less than 1% of all elective, major cardiac operations. Patient predictors included advanced age, female gender, and several chronic comorbidities. Teaching institutions had the highest odds of CDI but lowest odds of case fatality. Further investigation of factors contributing to CDI is warranted to disseminate institutional best practices.

P845 Impact of Clostridium difficile infection in patients admitted with ulcerative colitis

Abstract Background Clostridium diffile (CD) infection it is becoming increasingly more prevalent in general population and especially in patients with inflammatory bowel diseases (IBD). Patients with ulcerative colitis (UC) with CD infection during a flare can present greater morbidity and mortality. The objectives of the study were (a) to evaluate the proportion of CD infection in patients admitted with UC; (b) to compare the rates of colectomy in UC admitted with and without CD infection; (c) to analyse the association between the infection and worse results according to readmissions, need of treatment intensification and hospital stay; and (d) to describe predictive factors associated with worse evolution in patients with CD infections. Methods Cases and controls retrospective study. We included patients admitted due to a flare of UC in our hospital from 2000 to 2018. Variables related to hospital stay, adverse events, need of colectomy in the first year and mortality were collected. We analysed the data with SPSS using chi-square test, Kruskal–Wallis and multivariant analysis to identify factors of bad evolution. Results We analysed 235 admitted patients with UC flare. 62.1% male, mean age 43.6 years old (SD 12). Seventy-two per cent presented extensive colitis and 22% left coliits. 7.7% had perianal disease and 8.7% extraintestinal manifestations. Endoscopic activity was 75.8% Mayo Index 3 and 23% Mayo Index 2. 15.9% of the patients had complications during their hospitalisation related to their disease: 37.8% had toxic megacolon, 11% perforation and 11.2% of the total needed surgery during the hospitalisation. Twenty-eight patients (12.2%) had CD infection, among them 23.5% suffered recurrence infection of CD. This infection was statistically significant related to a higher rate of readmission (48.1% vs. 23%, p = 0.007) and higher rates of colectomy during the first year from the admission (13% vs. 2.9%, p = 0.05). We did not find differences among both groups of patients in terms of complications of their IBD, neither need of treatment intensification, nor mortality. Predictive factors of bad evolution were not identify with multivariant analysis. Conclusion CD infection is prevalent in UC admitted patients, with high rates of recurrence, this infection is related with higher rates of readmission and bigger need of colectomy during the first year.

133 Impact of Clostridium difficile Infection in Patients With Ulcerative Colitis and Crohn's Disease: A Comparative Analysis

INTRODUCTION: Patients with Inflammatory bowel disease (IBD) are at increased risk of acquiring Clostridium difficile infection (CDI) that leads to an increased in morbidity and mortality. The aim of our study is to compare the outcomes of CDI on in-hospital mortality and resource utilization among adult hospitalized patients with Ulcerative colitis (UC) and Crohn's disease (CD) without CDI in the USA. METHODS: A retrospective cohort analysis using the 2004–2014 Nationwide Inpatient Sample is performed. Adult hospitalized patients with IBD (subgrouped into UC and CD) with CDI were identified using validated ICD-9 codes. Outcomes include in-patient mortality, hospital charges, and length of stay (LOS) among two groups. Confounding factors such as age, sex, ethnicity, insurance status, hospital characteristics, and CDI are adjusted with univariate and multivariate regression models. RESULTS: Out of total 514,889 UC patient's hospitalizations, 24,783 (4.81%) discharges were related to CDI with mean age 60 ± 3 years and 60% female population. In comparison to that, out of 878,896 CD hospitalizations, 13,120 (1.49%) were related to CDI (see Table 1). In terms of outcomes, patients with UC + CDI had increased mortality (adjusted OR 3.003, 95% CI 2.65–3.39), P = 0.00 and LOS (8.0 days vs 6.5 days) and mean total charges difference of $16,739.33 as compared to UC patients without CDI. However, in contrast to CD patients with CDI, there was no significant difference in mortality (adjusted OR 0.60, 95% CI 0.40–0.90, P = 0.021), mean LOS (6.57 days vs 6.15 days) and total hospitalization charges ($34,137.16 VS $33,020.09) in comparison to CD patients without CDI. CONCLUSION: Our study results provide important insight on the effect of CDI on the outcome in patients with IBD. Surprisingly, we found that among US adults with UC and CD-related hospitalizations, CDI is associated with significantly subgrouped in-hospital mortality and healthcare utilization only in patients with UC and CDI infection did not appear to affect the outcomes in the CD-related hospitalizations.

Early Readmission Predicts Increased Mortality in Cirrhosis Patients After Clostridium difficile Infection.

We sought to determine the impact of Clostridium difficile infections (CDI) in cirrhosis by evaluating trends and outcomes of early readmission and mortality. The incidence of CDI in cirrhotics is increasing. We analyzed the Nationwide Readmissions Database (2011 to 2014) for hospitalized patients with CDI and differentiated them by presence of cirrhosis. Baseline characteristics, surgical rates, and outcomes were collected. The primary outcomes of interest included readmission and mortality rates. Of 366,283 patients hospitalized with CDI, 12,274 (3.4%) had cirrhosis, of which 7741 (63.1%) were decompensated. Among patients with CDI, 30-day readmission rates (33% vs. 24%), index admission mortality (5% vs. 2.5%), and calendar-year mortality (9% vs. 4%) were higher in patients with cirrhosis compared with those without cirrhosis. Recurrent CDI (rCDI) (46%) and cirrhosis-related complications (34.6%) were the most common reasons for readmission. Patients with decompensated cirrhosis were more likely to be readmitted within 30-days than those with compensated cirrhosis [odds ratio (OR), 1.19; 95% confidence interval (CI), 1.03-1.36]. Multivariable analyses revealed that among patients with cirrhosis, index colectomy (OR, 6.50; 95% CI, 1.61-26.24) and decompensation (OR, 3.61; 95% CI, 2.49-5.23) predicted index admission mortality. In addition, 30-day readmission (OR, 3.71; 95% CI, 2.95-4.67) and decompensated cirrhosis (OR, 1.49; 95% CI, 1.17-1.89) independently predicted calendar-year mortality. One-third of CDI patients with cirrhosis were readmitted within 30-days, most commonly because of rCDI. The mortality associated with CDI in patients with cirrhosis is high, with decompensation and 30-day readmission heralding a poor prognosis. Reducing rCDI-related readmissions may potentially improve these outcomes.

Pancreatic disease patients are at higher risk for Clostridium difficile infection compared to those with other co-morbidities

BackgroundSurveillance of Clostridium difficile infection (CDI) in patients with underlying diseases is important because use of prophylactic antibiotics makes them prone to CDI. Epidemiology of CDI in this high-risk population is poorly understood. A study was conducted to evaluate the impact of CDI in patients with specific underlying co-morbidities.MethodA total of 2036 patients, whose fecal samples were processed for C. difficile toxin A and B assay by ELISA formed the basis of study. Patients with underlying diseases were classified based on the organ/kind of disease as pancreatic (n = 340), renal (n = 408), hepatic (n = 245), malignant (n = 517) and miscellaneous disease (n = 526). Laboratory records of clinical and demographic details were reviewed. The association of CDI with age, gender, antibiotic receipt, clinical symptoms and underlying co-morbidities was analyzed. Variation in CDI cases based on age groups was also investigated.ResultClostridium difficile toxin positivity was 21.6% in general, whereas it was 30.6% in the pancreatic, 17.9% in the renal, 19.6%, in the hepatic, 21.3% in the malignancy and 20.0% in the miscellaneous disease groups. Toxin positivity was the lowest (14.8%) for female gender under renal disease and the highest (31.8%) for patients aged 40 to < 60 years, under pancreatic disease. Bloody diarrhea was a significant predictor for C. difficile toxin positivity. C. difficile toxin status irrespective to the underlying diseases was neither dependent on gender, age-groups or the number of antibiotics used. Association between patients’ gender, age and antibiotics receipt with underlying disease conditions, respective to C. difficile toxin status showed significance in relation to male gender (p < 0.05), age 40 to < 60 years (p = 0.03) and those receiving single (p = 0.09) or multiple antibiotics (p = 0.07).ConclusionPancreatic disease patients are at a higher risk for developing CDI, and particularly male gender, age 40 to < 60 years and those receiving antibiotics are at significant risk.

Clostridium difficile colitis in patients undergoing surgery for hip fractures: an analysis of 17,474 patients.

We compiled evidence from a large national surgical database to identify the incidence, risk factors and postoperative impact of Clostridium difficile infection (CDI) in patients undergoing hip fracture repair. We identified 17,474 patients who underwent hip fracture repairs in 2015 using the ACS-NSQIP database. Interventions studied were open reduction/Internal fixation, total hip arthroplasty or hemiarthroplasty being performed for traumatic hip fractures. Outcomes studied were incidence, preoperative and postoperative risk factors for occurrence of CDI were studied using descriptive and statistical analysis. A total of 92 patients (0.53%) developed CDI within 30 days of the operation. Following adjustment using multi-variate logistic regression, preoperative and hospital-associated factors associated with development of CDI were smoking (OR 1.75 [95% CI 1.03-2.99]), hypertension (OR 1.70 [95% CI 1.01-2.85]), hyponatraemia (OR 1.65 [95% CI 1.04-2.63]), prior systemic inflammatory response syndrome (SIRS) (OR 2.18 [95% CI 1.32-3.59]) and a length of stay >7 days (OR 1.98 [95% CI 1.11-3.53]. Postoperative factors associated with occurrence of CDI were occurrence of a deep surgical site infection (SSI) (OR 5.89 [95% CI 1.31-26.6]), a stay in the hospital >30 days (OR 6.56 [95% CI 2.56-16.9]) and unplanned reoperations (OR 2.78 [95% CI 1.29-5.99]). As we move toward an era of bundled-payment models, identification of risk factors associated with the occurrence of postoperative complications, such as CDI, will help curb excess healthcare utilisation and costs associated with the management of this complication.

The Impact of Clostridium difficile Infection on Mortality in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

Clostridium difficile infection (CDI) has been associated with an increased mortality risk among patients with inflammatory bowel disease (IBD) in multiple observational studies. We performed a systematic review and meta-analysis to help clearly define the magnitude of risk in IBD patients with and without CDI, and to assess the risk in individual IBD subtypes. A systematic search of multiple electronic databases was conducted for observational studies reporting the risk of mortality in IBD, stratified by the presence of CDI. Weighted summary estimates were calculated using generalized inverse variance with random-effects model. Study quality was assessed using the Newcastle-Ottawa scale. Ten observational studies were identified (8 from North America and 2 from Europe) and included 40,700 IBD patients with CDI and 1,320,764 IBD controls without CDI. Overall, IBD patients with CDI had a higher risk of mortality compared with IBD patients without CDI [odds ratios (OR), 4.39; 95% confidence interval (CI), 3.56-5.42; I=93%]. The results were stable in high-quality studies and in hospitalized patients. When patients were stratified by IBD type, CDI was associated with increased mortality in patients with ulcerative colitis (7 studies) (OR, 4.39; 95% CI, 3.44-5.61; I), but not in patients with Crohn's disease (4 studies) (OR, 2.21; 95% CI, 0.84-5.77; I). Individual studies were limited by an inability to control for IBD disease activity and therapeutic interventions. On the basis of 10 observational studies with at least moderate quality, CDI seems to increase mortality risk in IBD, particularly in ulcerative colitis. These findings are a cause for concern and suggest that CDI should be managed aggressively in patients with IBD.

Retrospective analysis of Clostridium difficile infection in patients with ulcerative colitis in a tertiary hospital in China

BackgroundMany reports have documented the increasing impact of Clostridium difficile infection (CDI) in patients with ulcerative colitis (UC). We conducted a retrospective study to determine the incidence, clinical characteristics, risk factors and prognosis of CDI in patients with UC.MethodsWe studied patients with UC, hospitalized between January 2010 and December 2015 in a tertiary hospital in China. Stool samples were tested for C. difficile toxins A and B (CDAB) by enzyme immunoassays in UC patients with disease flare. CDI in UC patients was diagnosed by clinical symptoms and positive CDAB test, and each case was matched with CDAB-negative patients in a 1:2 ratio. Univariate and binary logistic regression analyses were used to measure the differences between patients with and without CDI.ResultsThirty-four (8.92%) of 381 patients with UC were CDAB positive. Antibiotic exposure within 3 months prior to the study (P = 0.004), hospitalization within 1 month prior to the study (P = 0.025), systemic use of steroids (P = 0.002) and active cytomegalovirus (CMV) infection (P = 0.001) were higher in CDI than non-CDI patients. Binary logistic regression analysis revealed that CMV infection was associated with CDI (odds ratio = 13.502, 95% confidence interval 1.307–139.512, P = 0.029). UC patients with C. difficile and CMV co-infection had more severe colonoscopic features.ConclusionsRecent use of antibiotics, prior hospitalization and systemic use of steroids increased the risk of CDI. CMV infection was an independent risk factor of CDI in patients with UC.

Among inpatients, ischemic bowel disease predisposes to Clostridium difficile infection with concomitant higher mortality and worse outcomes.

Clinical conditions resulting in hypoxia, hypoperfusion, anaerobic milieu within the gut, and intestinal epithelial breakdown, such as seen in heart failure, precipitates Clostridium difficile infection (CDI). Given that ischemic bowel disease (IB) typically results in similar changes within the gut, we investigated the relationship between CDI and IB, and the impact of CDI on the clinical outcomes of IB. We initially performed a cross-sectional analysis on the 2014 Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (NIS) patient's discharge records of ages 18 years and older, by estimating the crude and adjusted odds ratio (aOR) of CDI and IB as the outcome and predictor respectively. We then pooled data from the 2012-2014 NIS, identified, and compared mortality (and 15 other outcomes) between three groups: IB+CDI, IB-alone, and CDI-alone (Statistical Analysis System 9.4). In the 2014 NIS, records with IB (n=27 609), had higher rate and odds of CDI [3.95 vs. 1.17%, aOR: 1.89 (1.77-2.02)] than records without IB (n=5 879 943). The 2012-2014 NIS contained 1105 IB+CDI, 30 960 IB-alone, and 60 758 CDI-alone groups. IB+CDI had higher mortality [aOR: 1.44 (1.11-1.86)], length of stay [9.59 (9.03-10.20) vs. 6.12 (5.99-6.26) days], cost [$93 257 (82 892-104 919) vs. $63 257 (61 029-65 567)], unfavorable discharge disposition [aOR: 2.24 (1.91-2.64)] and poorer results across most of the other outcomes than IB-alone. Comparable results were found for IB+CDI versus CDI-alone. IB is a risk factor for CDI in hospitals. CDI is associated with higher mortality, longer length of stay, higher cost, unfavorable discharge, and many other poorer health outcomes in patients with IB.

Prevalence and Impact of Clostridium difficile Infection (CDI) in Pregnancy

Introduction: The CDI epidemic is causing a major burden on our healthcare system. Prior studies have suggested that peripartum CDI may be increasing in morbidity and mortality. Our goal was to analyze whether this trend is being seen on a national scale in the United States. Methods: We retrospectively identified women with a primary or secondary discharge diagnosis of Pregnancy (ICD-9 V22.0, V22.1, v22.2) with and without Clostridium difficile infection (ICD-9 008.45) between 2005 and 2012 using the Nationwide Inpatient Sample Database. Pregnant women with CDI were compared with pregnant women without CDI for baseline characteristics as well as CDI and pregnancy-related outcomes including in-hospital mortality. 20 patients from both groups were then matched using propensity matching in a 1:1 ratio for demographic factors such as race, insurance and comorbidities including DM, hyperlipidemia, obesity, smoking status, and IBD. Cohorts were compared and matched using SAS 9.3. Results: During the study period, 26,103 pregnant patients were hospitalized within the United States. 0.08% (N=20) pregnant patients were hospitalized with a diagnosis of CDI. Both groups, Pregnant+CDI and Pregnant-CDI had similar baseline characteristics. Pregnant+CDI were more likely to develop toxic megacolon (9.1% vs 0.1%, p<0.001), ileus (4.6% vs 0.2%, p<0.001) and electrolyte disturbances such as hypokalemia (18.2% vs 2.9%, p<0.001) and hyponatremia (4.6% vs 0.7%, p=0.03). Pregnant women with Crohn’s disease were more likely to have CDI (4.6% vs 0.4%, p<0.001) compared to those without Crohn’s disease. CDI in pregnancy was not associated with increase in inpatient mortality both before (0.0% vs 0.1%, p=0.9) and after match (0% vs 0%, p=1.0). Conclusion: The prevalence of peripartum CDI in hospitalized patients seems to be low. Pregnant patients admitted with CDI are at increased risk for megacolon and therefore might benefit from more aggressive therapy. Future larger studies are needed to clarify epidemiologic trends, outcomes and optimal therapies for pregnant pts with CDI.

Impact of Clostridium difficile Colitis on Hospitalizations With End Stage Renal Disease (ESRD)

Introduction: Clostridium difficile infection (CDI) is a leading cause of healthcare associated diarrhea, accounting for 12% of healthcare-associated infections. End stage renal disease (ESRD) has been associated with an increased risk of incident and recurrent CDI, as well as higher in-hospital mortality and poor treatment response among those hospitalized for CDI. However, the impact of CDI among those hospitalized with a primary or secondary diagnosis of ESRD has not been well studied in a large contemporary data base. A more complete understanding of factors related to CDI during hospitalization for ESRD could facilitate the development of more effective preventive strategies. Methods: We utilized the National Inpatient Sample (NIS) to identify all hospitalizations with a primary or secondary discharge diagnosis of ESRD (ICD-9 CM code 585.6) during the years 2005-2011. Hospitalizations complicated by CDI (ICD-9 CM code 008.45) in this cohort were then identified, and analyzed. Statistical significance of variation in the number of hospital discharges, demographics, cost of care, comorbidity measures and outcomes during the study period was determined using Cochran-Armitage trend test. Results: In 2005, there were 165,344 hospitalizations with discharge diagnoses of ESRD compared to 1,029,371 in 2011 (p-trend< 0.0001, Figure 1A). The percentage of hospitalizations with CDI increased from 2.04% in 2005 to 2.40% in 2011 (p-trend< 0.0001, figure 1B). All-cause inpatient mortality showed a numerical but nonsignificant increase (13.16% in 2005 to 14.76% in 2011) (p= 0.79, figure 1C). Cost of care increased from $31,336 in 2005 to $42,375 in 2011 (adjusted for inflation, p-trend< 0.0001, figure 1D). Analysis of the Agency for Healthcare Research and Quality (AHRQ) comorbidity measures revealed that hypertension, anemia and diabetes mellitus were some of the most commonly associated comorbidities (Figure 2).137_A Figure 1 No Caption available.137_B Figure 2 No Caption available.Conclusion: A significant increase in the number of hospitalizations for ESRD complicated by CDI was seen during the study period. Although there was no significant increase in in-hospital mortality associated with these hospitalizations, there was a significant rise in the cost of care, perhaps due to longer hospital stay, multiple interventions and increasing numbers of comorbid conditions. Further studies will be required to more fully understand how these factors influence the development and severity of CDI during hospitalization.

Clostridioides (Formerly Clostridium) difficile Infection During Hospitalization Increases the Likelihood of Nonhome Patient Discharge.

Clostridioides (formerly Clostridium) difficile infection (CDI) is associated with significant morbidity and mortality, including frequent hospitalizations. However, the impact of CDI after hospital discharge is poorly understood. The purpose of this study was to assess patient discharge disposition and understand CDI-related risk factors for nonhome discharge. Using a nationally representative database of Veterans Health Administration (VHA) patients (2003-2014) and a validation database from hospitalized non-VHA patients in Houston, Texas, admission and discharge disposition was obtained for patients with CDI and matched controls. Incidence of and clinical/microbiologic risk factors for nonhome discharge were assessed using these databases. A total of 15173 VHA patients with CDI and 48599 non-CDI control patients originally admitted from the community were included. Significantly more patients with CDI were discharged to a nonhome location compared with controls (18% vs 8%; P < .0001), most commonly hospice/death (12%) or nursing home/long-term care facility (6%). Results were confirmed using a propensity-matched analysis and a validation cohort of 1941 hospitalized patients with CDI in Houston, Texas. Age, comorbidities, severe CDI, and ribotypes F027, F001, and F053-163 were associated with a nonhome discharge (P < .05 for all). Hospitalized patients with CDI frequently required a higher level of medical care residence at discharge compared with non-CDI patients. Risk factors for discharge to a higher level of care included CDI disease severity and variables associated with recurrent CDI.

Incidence, Risk Factors, and Outcomes of Clostridium difficile Infections in Kidney Transplant Recipients.

Kidney transplant recipients (KTR) may be at increased risk for Clostridium difficile infections (CDI) but risk factors and outcomes in this population have not been well studied. An observational cohort study was conducted to determine the incidence, risk factors, and outcomes of CDI in KTR. A total of 1816 KTR transplanted between 2000 and 2013 at the Toronto General Hospital were included. Sixty-eight patients developed CDI. Controls were selected at a 4:1 ratio using risk-set sampling, and risk factors were explored using conditional logistic regression models. The impact of CDI on graft outcomes was evaluated using Cox proportional hazards models. The incidence rate of CDI was 0.64 cases/100 person-years. Independent predictors of CDI included antibiotic use (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.35-6.15), increased duration of hospitalization posttransplant (OR, 1.04; 95% CI, 1.02-1.06]), receiving a deceased donor kidney (OR, 2.98; 95% CI, 1.47-6.05), and a history of biopsy-proven acute rejection (OR, 5.82; 95% CI, 2.22-15.26). In the Cox proportional hazards model, CDI was found to be an independent risk factor for the subsequent development of biopsy-proven acute rejection (hazard ratio, 2.18; 95% CI, 1.34-3.55). Our results confirm that transplant-specific factors place KTR at a higher risk for CDI. Clostridium difficile infections may increase the risk of adverse outcomes, such as biopsy-proven acute rejection. These findings emphasize the importance of preventive strategies to reduce the morbidity associated with CDI in KTR.