Clostridium Difficile Infection Mortality Research Articles

S233 Prevalence, Trends, and Mortality of Clostridium difficile Infection in Hospitalized Elderly Patients with HIV: A Nationwide Analysis From 2016-2019

S233 Prevalence, Trends, and Mortality of Clostridium difficile Infection in Hospitalized Elderly Patients with HIV: A Nationwide Analysis From 2016-2019

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.

Change in the Mortality Trend of Hospitalized Patients with Clostridium difficile Infection: A Nation-wide Study.

BackgroundAccording to the Healthcare Cost and Utilization Project (HCUP), mortality in Clostridium difficile infection (CDI) has been rising since 2009, and an upward trend in mortality has been noted. Although there have been studies exploring the incidence of CDI and mortality in the national database, those studies were limited to one particular year. With the advent of newer modalities of diagnosis and treatment for CDI, the recent multiyear trend in disease-specific outcomes from large administrative databases is unknown.ObjectiveTo study the recent trend in nationwide hospital admissions and mortality along with hospital outcomes.MethodsWe queried the identified National Inpatient Sample from 2007 to 2011 to identify patients of age >18 years, with a discharge diagnosis of CDI identified by the International Classification of Diseases, 9th edition (ICD-9), clinical modification codes 008.45, respectively.ResultsWe identified a decline in CDI mortality to 2.67% in 2011 as compared to 3.83% in 2007 (P<0.0001) with CDI as the primary discharge diagnosis and a downward trend in all-cause mortality from 9.2% in 2007 to 7.9% in 2011 (P<0.0001). We identified an upward trend in CDI-related hospital discharges from 2007 (N=325,022) to 2011 (N=333498). Hospital discharges with CDI as a primary discharge diagnosis also increased from 2007 (N=104,123) to 2011 (123,898). The mean length of stay decreased from 7.16 days in 2007 to 6.40 days in 2011 (P 0.0001). CDI was noted to be more common in the elderly (61-80), with a mean age of 68 years. Patients were of Caucasian descent (67%), female (64%), and primarily a Medicare payer (69%). Mean hospital charges increased from $31,551 to 35,654$ (P .04). Of interest, CDI was noted to be more common in large bed-sized non-teaching hospitals (57%) than large bed-sized teaching hospitals (42%). In terms of the geographical distribution of CDI, the southern states of the US had an increased incidence of CDI (36%) and the west coast (16%) had the least incidence.Conclusion Our study shows an improved trend in-hospital mortality outcomes and a decreased length of stay likely related to the advancement in CDI treatments. Hospital charges were increased from 2007 to 2011 in spite of a decrease in hospital length of stay.

Nonsteroidal Anti-Inflammatory Drugs Impact on the Outcomes of Hospitalized Patients with Clostridium difficile Infection.

PurposeMouse model experiments have demonstrated an increased Clostridium difficile infection (CDI) severity with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) use. We aim to evaluate the impact of NSAIDs in humans after a diagnosis of CDI on primary outcomes defined as I) all-cause mortality and II) toxic mega-colon attributable to CDI.Patients and methodsAll hospitalized patients with a diagnosis of CDI were divided into two groups; those with NSAIDs administered up to 10 days after onset of CDI versus no NSAIDs use. The primary outcomes were analyzed between the groups, while controlling for severity of CDI. A logistic regression analysis was performed to identify the predictors of worse outcomes.ResultsNSAIDs were administered in 14% (n=80) of the 568 hospitalized visits for an average of 2.5 days after the CDI diagnosis. All-cause mortality was high in patients who did not receive NSAIDs as compared to those who did receive NSAIDs (16.6% vs 12.5%, p 0.354). Patients who were prescribed NSAIDs were more likely to have toxic mega-colon as compared to those who were not prescribed NSAIDs (2.5% vs 0.6%, p 0.094). Results were not statistically significant, even after controlling for CDI severity. Logistic regression analysis did not identify NSAIDs administration as a significant factor for all-cause mortality in CDI patients.ConclusionThis retrospective study results, contrary to mouse model, did not show association between NSAID use and CDI related mortality and toxic mega-colon. Shorter duration of NSAIDs use, younger people in study group, and timely CDI treatment may have resulted in contrasting results.

223 Does “Prior Appendectomy” Affect the Outcomes of Clostridium difficile Infection in Hospitalized Patients? A Retrospective Review and Analysis

INTRODUCTION: Clostridium difficile infection (CDI) is prevalent in hospitalized patients and accounts for significant morbidity and mortality. Management and outcomes of these patients depend on the severity of CDI. Current classification of severity of CDI includes parameters that depict its inflammatory response. We attempted to study the influence of prior appendectomy on severity and outcomes of CDI. METHODS: We conducted a retrospective chart review of 1248 patients admitted to our institute between 2008 and 2016, whose stool tested positive for Clostridium difficile toxin. Baseline characteristics, comorbidities, and lab values were extracted from the EMR. Information regarding prior appendectomy was obtained from medical documentation and abdominal imaging, whichever was available. Patients were grouped into those with prior appendectomy (group A) and those without (group B). In-hospital Mortality was defined as death during the same hospital admission as CDI. Severity was defined as per the Infectious Diseases Society of America guidelines. The primary outcomes were to 1) assess all-cause in-patient mortality and 2) severity of CDI, attributable to prior appendectomy. RESULTS: There were a total of 1248 patients of which 13.5% (n = 175) had a history of prior appendectomy. The mean age was similar in both groups (57 years), and baseline characteristics were comparable. There was a female preponderance (60.06%) in group A. The dominant patient race was African American (36.6% in group A and 39.8% in group B). All lab parameters were similar in both groups, except WBC counts, which were higher amongst patients with appendectomy (13 vs. 11, ±8) (P 0.013). Group A patients were more likely to have a severe presentation of CDI (40%, n = 68), whereas group B had mostly mild CDI (45.9%, n = 492). Prior appendectomy did affect the severity status, although statistical significance was not achieved (P 0.057). There was no statistical difference in mortality either, with 25 deaths in group A (14.3%) and 169 in group B (15.8%) (P 0.62). Regression analysis performed to ascertain independent predictors of all-cause mortality in CDI did not identify prior appendectomy as a risk factor. CONCLUSION: Prior appendectomy status may affect the severity of CDI and hence the need for colectomy. However, we did not observe a difference in mortality associated with prior appendectomy. Since the prevalence of prior appendectomy was low in our study, larger population studies are needed to establish significant outcomes.

Malnutrition as a risk factor for mortality in clostridium difficile infection

Malnutrition as a risk factor for mortality in clostridium difficile infection

Clinical features of Clostridium difficile infection in an intensive care unit: from 2009 to 2017

Background: The incidence, severity and mortality of Clostridium difficile infection (CDI) has been on the rise over the last 20 year and its mortality has been estimated in 6-38%. Our aims are to determine clinical characteristics of CDI and factors related to mortality in an intensive care unit (ICU). Methods & Materials: Among 1122 patients living with HIV admitted to ICU between 2009 and 2016, 60 had CDI. Univariate analysis was performed to identify death related factors. Results are expressed as percentage (%), median (Me), mean (M) and range. A p value of < 0.05 was considered significant Results: Incidence was 0,02, it was found to be 61% higher between 2014-2017. 60% men. M/Me age were 47 years. M/Me time from admission to diarrhea onset was 46/33 days. Estimated length of IC stay before CDI acquisition was M/Me 14/10 days. 93% had an underlying medical condition, 62% HIV/Aids. Use of antibiotics 95%; M/Me prior exposure of 29/19 days. 100% were undergoing gastric acid suppression (GAS). Most common symptoms/signs were: 95% diarrhea, 52% abdominal pain and 48% arterial hypotension. 90% present hypoalbuminemia less than 3,5 g/L, Me 2,2 g/L. 95% were diagnosed with enzyme immunoassays for toxins A/B. Patients developed mild/moderated CDI 38%, severe 53%, complicated 37% and 8% recurred. M/Me APACHE II score (Score Acute Physiology and Chronic Health Evaluation II) on IC admission of 19 points and M/Me SOFA (Sequential Organ Failure Assessment score) of 5 points. 7% were not treated. Overall mortality was 61%; an increased mortality 108% was noted when 2 periods were compared (2009-2013 and 2014-2017). Hypoalbuminemia (≤2,4 g/L), APACHE II > 18 points, SOFA > 5 points, severe CDI present statistically significant in mortality (p < 0,05) Conclusion: More than a half occured in HIV seropositive individuals. Almost 100% had been exposed to antibiotics and 100% to GAS. More than half were severe, a factor that as well as hypoalbuminemia, and the severity scores used in the ICU, are associated with higher mortality. Mortality associated with CDI increased during the study period and was more likely to occur in younger patients and in hospitalizations lasting longer than 4 wk.

Trends in mortality following Clostridium difficile infection in Scotland, 2010–2016: a retrospective cohort and case–control study

National surveillance of Clostridium difficile infection (CDI) in Scotland enables the monitoring of trends in incidence rates but not mortality. To assess factors associated with mortality for all CDI cases aged ≥15 years in Scotland between 2010 and 2016. All CDI cases aged ≥15 years in Scotland between 2010 and 2016 were linked to hospital admission and mortality datasets. Logistic regression was used to assess factors associated with mortality (30-day all-cause). A case-control study of a hospitalized subset of cases and matched hospitalized controls assessed the impact of CDI on mortality and length of stay. Thirty-day all-cause mortality decreased over the seven-year period (from 20.5% to 15.6%; P<0.001), mainly among healthcare-associated CDI (HA-CDI). Increased age, higher Charlson score, HA-CDI, as well as liver, heart and malignancy comorbidities were associated with higher mortality. No association was observed between polymerase chain reaction ribotype and higher mortality, though 015 and 078 were associated with lower mortality. Adjusted odds ratio (OR) for 30-day mortality in hospitalized CDI cases compared to controls was 2.67 (95% confidence interval (CI): 2.42-2.94; P<0.001). Whereas mortality declined over time in cases and controls, the trend in ORs remained relatively stable. Having CDI increased additional mean length of stay beyond infection by 22.3% (95% CI: 18.0-26.8%; P<0.001). CDI is associated with an almost three-fold increase in 30-day mortality and places an increased burden on hospital resources by increasing mean LOS beyond the infection date by 22.3%. The decreasing CDI mortality trends may be due to overall improvements in mortality among the general and hospital population of Scotland. Therefore, despite large declines in incidence rates, CDI remains a serious healthcare problem.

External validation of predictive scores for mortality following Clostridium difficile infection

BackgroundThe burden of Clostridium difficile infection (CDI) has increased in the last decade, with more adverse outcomes and related mortality. Although many predictive scores were developed, few were validated and their performances were sub-optimal. We conducted an external validation study of predictive scores or models for mortality in CDI.MethodsPublished predictive tools were identified through a systematic review. We included those reporting at least an internal validation approach. A multicenter prospective cohort of 1380 adults with confirmed CDI enrolled in two Canadian provinces was used for external validation. Most cases were elderly (median age 71), had a healthcare facility-associated CDI (90%), and 52% were infected by NAP1/BI/027 strains. All-cause 30-day death occurred in 12% of patients. The performance of each scoring system was analyzed using individual primary outcomes.ResultsWe identified two scores which performances (95% CI) are shown in the table. Both had low sensitivity and PPV, moderate specificity and NPV, and similar AUC/ROC (0.66 vs. 0.77 in the derivation cohort, and 0.69 vs. 0.75 respectively). One predictive model for 30 days all-cause mortality (Archbald-Pannone 2015, including Charlson score, WBC, BUN, diagnosis in ICU, and delirium*) was associated with only 5% increase in odds of death (crude OR = 1.05 (1.03–1.06)) with an AUC of 0.74 (0.7–0.8).Study, outcome (%)Predictors (assigned points)Cutoff/ max scoreSen %Spe %PPV %NPV %LR +Accuracy %Kassam 2016 In hospital CDI-related mortality (18%)Age (2–4) ICU admission (5) Acute renal failure* (3) Diabetes (-1) Cardiopulmonary disease* (1) Liver disease (2) IBD (2) Malignancy (2)≥6 patients/1944 (37–51)79 77–82)31 26–37)87 84–89)2.1 2–2.2)73 70-76)Butt 2013 30-day all-cause mortality (12%)Serum albumin ≤ 24.5 g/L (1) CRP > 228 mg/L (1) WBC > 12 and/or respiratory rate > 17/minute (1)≥2 patients/356 46–64)77 74–80)25 20–30)93 (90–94)2.4 2.3–2.5)74 (71–77) *Modified to match available data in validation cohort.ConclusionThe predictive models of CDI mortality evaluated in our study have limitations in their methods and showed moderate performances in a validation cohort consisting of a majority of CDI caused by NAP1 strains. An accurate predictive tool is needed to guide clinicians in the management of CDI to prevent adverse outcomes.Disclosures J. Powis, Merck: Grant Investigator, Research grant; GSK: Grant Investigator, Research grant; Roche: Grant Investigator, Research grant; Synthetic Biologicals: Investigator, Research grant

Mortality of Clostridium difficile Infection in Patients With Gastrointestinal Cancers

Mortality of Clostridium difficile Infection in Patients With Gastrointestinal Cancers

Mathematical Modeling of the Transmission Dynamics of Clostridium difficile Infection and Colonization in Healthcare Settings: A Systematic Review.

BackgroundWe conducted a systematic review of mathematical models of transmission dynamic of Clostridium difficile infection (CDI) in healthcare settings, to provide an overview of existing models and their assessment of different CDI control strategies.MethodsWe searched MEDLINE, EMBASE and Web of Science up to February 3, 2016 for transmission-dynamic models of Clostridium difficile in healthcare settings. The models were compared based on their natural history representation of Clostridium difficile, which could include health states (S-E-A-I-R-D: Susceptible-Exposed-Asymptomatic-Infectious-Resistant-Deceased) and the possibility to include healthcare workers and visitors (vectors of transmission). Effectiveness of interventions was compared using the relative reduction (compared to no intervention or current practice) in outcomes such as incidence of colonization, CDI, CDI recurrence, CDI mortality, and length of stay.ResultsNine studies describing six different models met the inclusion criteria. Over time, the models have generally increased in complexity in terms of natural history and transmission dynamics and number/complexity of interventions/bundles of interventions examined. The models were categorized into four groups with respect to their natural history representation: S-A-I-R, S-E-A-I, S-A-I, and S-E-A-I-R-D. Seven studies examined the impact of CDI control strategies. Interventions aimed at controlling the transmission, lowering CDI vulnerability and reducing the risk of recurrence/mortality were predicted to reduce CDI incidence by 3–49%, 5–43% and 5–29%, respectively. Bundles of interventions were predicted to reduce CDI incidence by 14–84%.ConclusionsAlthough CDI is a major public health problem, there are very few published transmission-dynamic models of Clostridium difficile. Published models vary substantially in the interventions examined, the outcome measures used and the representation of the natural history of Clostridium difficile, which make it difficult to synthesize results and provide a clear picture of optimal intervention strategies. Future modeling efforts should pay specific attention to calibration, structural uncertainties, and transparent reporting practices.

High morbidity and mortality of Clostridium difficile infection and its associations with ribotype 002 in Hong Kong

We aim to study the disease burden, risk factors and severity of Clostridium difficile infection (CDI) in Hong Kong. We conducted a prospective, case-control study in three acute-care hospitals in Hong Kong. Adult inpatients who developed CDI diarrhoea confirmed by PCR (n=139) were compared with the non-CDI controls (n=114). Ribotyping of isolates and antimicrobial susceptibility testing were performed. The estimated crude annual incidence of CDI was 23-33/100,000 population, and 133-207/100,000 population among those aged ≥65 years. The mean age of CDI patients was 71.5. Nursing home care, recent hospitalization, antibiotics exposure (adjusted OR 3.0, 95% CI1.3-7.1) and proton-pump inhibitors use (adjusted OR 2.2, 95% CI1.2-3.9) were risk factors. Severe CDI occurred in 41.7%. Overall mortality was 16.5% (among severe CDI, 26.5%). The commonest ribotypes were 002 (22.8%), 014 (14.1%), 012 and 046; ribotype 027 was absent. Ribotype 002 was associated with fluoroquinolone resistance and higher mortality (47.6% vs. 12.7%; adjusted HR 2.8, 95% CI 1.1-7.0). Our findings show high morbidity and mortality of CDI in the older adults, and identify ribotype 002 as a possible virulent strain causing serious infections in this cohort.

Epidemiology and mortality of Clostridium difficile infection: a 5-year retrospective laboratory-based study in a large teaching hospital in Northern Italy

Clostridium difficile represents the major infective causes of hospital-acquired infectious diarrhoea and one of the most common microorganisms responsible for health-care associated infection.

Regional and seasonal variation in Clostridium difficile infections among hospitalized patients in the United States, 2001-2010

This study identified national regional and seasonal variations in Clostridium difficile infection (CDI) incidence and mortality among hospitalized patients in the United States over a 10-year period. This was a retrospective cohort study of the U.S. National Hospital Discharge Survey from 2001-2010. Eligible cases had an ICD-9-CM discharge diagnosis code for CDI (008.45). Data weights were used to derive national estimates. CDI incidence and mortality were presented descriptively. Regions were as defined by the U.S. Census Bureau. Seasons included the following: winter (December-February), spring (March-May), summer (June-August), and fall (September-November). These data represent 2.3 million CDI discharges. Overall, CDI incidence was highest in the Northeast (8.0 CDIs/1,000 discharges) and spring (6.2 CDIs/1,000 discharges). CDI incidence was lowest in the West (4.8 CDIs/1,000 discharges) and fall (5.6 CDIs/1,000 discharges). Peak CDI incidence among children occurred in the West (1.7 CDI/1,000 discharges) and winter (1.5 CDI/1,000 discharges). Mortality among all CDI patients was highest in the Midwest (7.3%) and during the winter (7.9%). The region and season with the highest CDI incidence rates among patients hospitalized in U.S. hospitals were the Northeast and spring, respectively. The highest CDI mortality rates were seen in the Midwest and winter. Children exhibited different regional and seasonal CDI variations compared with adults and older adults.

P-167 Serum Derived Bovine Immunoglobulin Enhances Overall Survival of Clostridium Difficile Associated Disease Accentuated by Malnutrition

The morbidity, mortality and financial costs of Clostridium difficile infection (CDI) have increased dramatically over the past decade. The primary virulence factors are toxins A and B. Risk factors for CDI include antibiotics, ages over 65, inflammatory bowel disease, gastrointestinal surgery and malnutrition. Serum-derived bovine immunoglobulin (SBI) is predominantly IgG and has been shown to bind and neutralize toxins A and B in vitro. Based on these results, we hypothesized that SBI would reduce mortality in an in vivo mouse model of CDI. Mice on a 5% protein (low, 25% of protein requirement by N.R.C.) or 20% protein (normal) diet were provided 40 mg/day SBI or hydrolyzed collagen (HC) in drinking water/oral gavage for the entire study. On day -5 a cocktail of antibiotics was orally administered for 3 days followed by parenteral clindamycin on day -1. Mice were challenged with 105 CFU C. difficile on day 0 and treated with vancomycin from days 0–4. Kaplan-Meier survival curves were generated. Overall, mice administered SBI had a significant reduction in CDI-associated mortality compared to HC-treated mice (P = 0.002). While the difference in survival when comparing SBI and HC in normal protein diets was not significant (P = 0.13), mice fed a low protein diet and SBI were substantially protected against mortality as shown in Figure 1 (P = 0.005). These results indicate that SBI is particularly effective at reducing CDI mortality in a state of malnutrition. Future studies will focus on how SBI and the interaction of malnutrition, affect colonization and resistance of C. difficile.

Statins use and risk of mortality in patient with Clostridium difficile infection

Current evidence suggests that statins may improve outcome in infectious diseases. This study aims to assess whether statins use is associated with reduced risk of 30-day mortality in Clostridium difficile infection (CDI). Using the computerized database of Clalit, the largest healthcare provider in Israel, we identified a cohort of adult subjects (age ≥40 years) who tested positive on a C. difficile toxin assay performed between January 2011 and December 2012. Subjects were defined as current statins users if they filled at least one prescription during the 90 days before the laboratory assay date. Current users were classified into long-term users if at least one additional prescription was filled during the previous 91-180 days; otherwise they were defined as short-term users. A total 1888 patients with CDI were included. Of them, 340 (18.0%) died during the first 30 days after diagnosis. The 30-day mortality rate was lower among current statins users 89/669 (13.3%) compared with 251/1219 (20.6%) in non-users (p <0.001). A significant reduced risk of 30-day mortality existed after adjustment for potential confounders; adjusted OR = 0.57 (95% CI 0.42-0.79) and was unique to long-term users; 0.53 (0.38-0.73) but not short-term users; 1.15 (0.56-2.34). The risk of 30-day mortality decreased with increasing number of filled statins prescriptions; adjusted OR = 0.77 (95% CI 0.67-0.89) for each additional prescription. Current aspirin use was also independently associated with reduced mortality; adjusted OR = 0.64 (95% CI 0.43-0.88). In conclusion, current statins use, particularly long-term use, has a dose-response protective effect on mortality in patients with CDI.

Clostridium Difficile Colitis

Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated and nosocomial infectious diarrhea. Presenting as clostridium difficile colitis, it is a significant cause of morbidity and mortality. Metronidazole is regarded as the agent of choice for CDl therapy and also for the first recurrence in most patients with mild to moderate CDI. Vancomycin is recommended as an initial therapy for patients with severe CDI. With recent Food and Drug Administration-approval fidaxomicin is available for clinical use and is as effective as vancomycin with lower relapse rates. Rifaximin and fecal bacteriotherapy are alternative approaches in patients with severe or refractory CDI, before surgical intervention. Antibiotic research is ongoing to add potential new drugs such as teicoplanin, ramoplanin, fusidic acid, nitazoxanide, rifampin, bacitracin to our armamentarium. Role of toxin-binding agents is still questionable. Monoclonal antibody and intravenous immunoglobulin are still investigational therapies that could be promising options. The ongoing challenges in the treatment of CDI include management of recurrence and presence of resistance strains such as NAP1/BI/027, but early recognition of surgical candidates can potentially decrease mortality in CDI.

Correction: Risk Factors for Recurrence, Complications and Mortality in Clostridium difficile Infection: A Systematic Review

Correction: Risk Factors for Recurrence, Complications and Mortality in Clostridium difficile Infection: A Systematic Review

Concordance of the SHEA-IDSA severity classification for Clostridium difficile infection and the ATLAS bedside scoring system in hospitalized adult patients.

The Society for Healthcare Epidemiology of America and Infectious Diseases Society of America (SHEA-IDSA) guidelines for the treatment of Clostridium difficile infection (CDI) recommend initial treatment of CDI based on disease severity. This severity definition has not been validated or evaluated based on clinical outcomes. The ATLAS scoring system is a validated tool useful in predicting treatment response and mortality in CDI. The main purpose of this study is to evaluate the concordance of the ATLAS scoring system and the SHEA-IDSA staging for CDI severity. This was a retrospective study which included hospitalized patients with confirmed CDI. Bivariate analyses compared baseline demographics and clinical information between patients with nonsevere and severe CDI based on the SHEA-IDSA criteria for CDI severity. Kappa scores were calculated to compare the concordance of the two scoring systems in defining CDI severity. Sensitivity and specificity of the ATLAS scoring system to determine CDI severity were calculated using the SHEA-IDSA criteria as the reference standard. Sixty-four patients met inclusion criteria. Of those, 62.5% were classified as mild to moderate CDI, 25% were severe, uncomplicated, and 12.5% were severe, complicated based on SHEA-IDSA criteria. In the bivariate analyses, ATLAS score breakpoints of ≥ 4, ≥ 5, and ≥ 6 revealed moderate agreement with the SHEA-IDSA classification for severity. The sensitivities and specificities for ATLAS scores in predicting CDI severity ranged from 58.3 to 87.5, and 67.5-87.5%, respectively. The ATLAS score may be useful in evaluating CDI severity and determining drug therapy selection.

Risk factors for recurrence, complications and mortality in Clostridium difficile infection: a systematic review.

Background Clostridium difficile infection (CDI) can lead to complications, recurrence, and death. Numerous studies have assessed risk factors for these unfavourable outcomes, but systematic reviews or meta-analyses published so far were limited in scope or in quality.MethodsA systematic review was completed according to PRISMA guidelines. An electronic search in five databases was performed. Studies published until October 2013 were included if risk factors for at least one CDI outcome were assessed with multivariate analyses.Results68 studies were included: 24 assessed risk factors for recurrence, 18 for complicated CDI, 8 for treatment failure, and 30 for mortality. Most studies accounted for mortality in the definition of complicated CDI. Important variables were inconsistently reported, such as previous episodes and use of antibiotics. Substantial heterogeneity and methodological limitations were noted, mainly in the sample size, the definition of the outcomes and periods of follow-up, precluding a meta-analysis. Older age, use of antibiotics after diagnosis, use of proton pump inhibitors, and strain type were the most frequent risk factors for recurrence. Older age, leucocytosis, renal failure and co-morbidities were frequent risk factors for complicated CDI. When considered alone, mortality was associated with age, co-morbidities, hypo-albuminemia, leucocytosis, acute renal failure, and infection with ribotype 027.ConclusionLaboratory parameters currently used in European and American guidelines to define patients at risk of a complicated CDI are adequate. Strategies for the management of CDI should be tailored according to the age of the patient, biological markers of severity, and underlying co-morbidities.