Attributable Outcomes of EndemicClostridium difficile–associated Disease in Nonsurgical Patients

Abstract

Data are limited on the attributable outcomes of Clostridium diffi cile-associated disease (CDAD), particularly in CDAD-endemic settings. We conducted a retrospective cohort study of nonsurgical inpatients admitted for >48 hours in 2003 (N = 18,050). The adjusted hazard ratios for readmission (hazard ratio 2.19, 95% confi dence interval [CI] 1.87-2.55) and deaths within 180 days (hazard ratio 1.23, 95% CI 1.03-1.46) were signifi cantly different among CDAD case-patients and noncase patients. In a propensity score matched-pairs analysis that used a nested subset of the cohort (N = 706), attributable length of stay attributable to CDAD was 2.8 days, attributable readmission at 180 days was 19.3%, and attributable death at 180 days was 5.7%. CDAD patients were signifi cantly more likely than controls to be discharged to a long-term-care facility or outside hospital. Even in a nonoutbreak setting, CDAD had a statistically signifi cant negative impact on patient illness and death, and the impact of CDAD persisted beyond hospital discharge.C lostridium diffi cile-associated disease (CDAD) is an increasingly common cause of hospital-associated diarrhea (1,2). The emerging NAP1 strain of C. diffi cile has been associated with numerous outbreaks and appears to be more virulent than other endemic and epidemic C. diffi cile strains (3-9). Despite the increasing importance of this pathogen, few data exist on outcomes attributable to CDAD (10-14). The attributable mortality for CDAD has recently been estimated at 6.9% and 16.7% (9,12). However, these studies were performed during CDAD outbreaks caused by the NAP1 strain. Published estimates of CDAD-attributable deaths in disease-endemic settings are much lower (1.2%-1.5%) (10,13). Kyne et al. did not fi nd endemic CDAD to be an independent predictor of death within 1 year of CDAD, but that study was relatively small (47 CDAD cases) (11). Thus, additional data with larger sample sizes are needed to determine outcomes associated with CDAD in nonoutbreak settings. With a large cohort of CDAD patients at a tertiary-care center, we evaluated CDAD outcomes including length of stay, hospital discharge status, time-to-readmission, and deaths in a CDADendemic setting. MethodsThis study was conducted at Barnes-Jewish Hospital (BJH), a 1,250-bed, tertiary-care academic hospital in St. Louis, Missouri. Eligibility was limited to nonsurgical patients admitted for >48 hours from January 1 through December 31, 2003. Nonsurgical patients were defi ned as those without operating room costs. Surgical patients were excluded because of their heterogeneity. Specifi cally, risk factors for length of stay, readmission to the hospital, and death were different in this population compared with other hospitalized patients. Data were primarily collected from the hospital's Medical Informatics database. The database was queried to collect patient demographics; admission and discharge dates; International Classifi cation of Diseases, 9th edition, Clinical Modifi cation (ICD-9-CM), diagnosis and procedur...

Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals

“…7,8 a. CDI increases mean length of hospital stay from 2.6 days to 4.5 days. 9,10 b. Attributable costs of inpatient CDI have been estimated to be $2,470-$3,669 per episode. Attributable inpatient costs during the 6 months after CDI diagnosis are $5,042-$7,179.…”

“…12 c. Patients with CDI were almost twice as likely to be discharged to a long-term care facility than were propensity score-matched control individuals. 9 d. CDI has recently been associated with an attributable mortality rate of 6.9% at 30 days after diagnosis and 16.7% at 1 year. 3,4,9 3.…”

“…9 d. CDI has recently been associated with an attributable mortality rate of 6.9% at 30 days after diagnosis and 16.7% at 1 year. 3,4,9 3. Changing risk factors and possible decrease in CDI treatment response rates a. Fluoroquinolones, previously infrequently associated with CDI, have been found to be one of the primary predisposing antimicrobials in recent studies.…”

Risk Factors for Acquisition and Loss of Clostridium difficile Colonization in Hospitalized Patients

“…lostridium difficile infection (CDI) is the most common infectious cause of hospital-associated diarrhea, and while most CDI infections are mild, severe CDI can lead to outcomes, such as toxic megacolon, colectomy, and death (1)(2)(3)(4). Current estimates of the excess health care costs associated with CDI in the United States are $4.8 billion per year (5).…”

Effectiveness of Screening Hospital Admissions to Detect Asymptomatic Carriers of Clostridium difficile: A Modeling Evaluation

“…In the United States, the number of discharges in which the patient was diagnosed with CDI doubled from 2000 to 2009; C. difficile is estimated to cause as many as 250,000 new infections and 14,000 deaths per year, and in US acute care facilities alone, the cost is as much as $3.2 billion per year. [1][2][3][4][5] In the latest report on antibiotic resistance threats in the United States released by the Centers for Disease Control and Prevention in 2013, C. difficile was classified within the highest threat level of urgent. 5 The increase in C. difficile infection rates is attributed partially to the emergence of the epidemic NAP1/B1/027 strain, which has high levels of toxin A and B production and carries the binary toxin.…”