Is Diarrhea Enough to Assess the Severity of Clostridium difficile–Associated Disease?

Reply to Jaber et al.

“…2 We agree that although diarrhea is the hallmark symptom of CDAD, a comprehensive CDAD severity grading system must also incorporate many of the symptoms that Jaber et al 1 mention. In fact, only 31 (84%) of 37 patients in our study had diarrhea that was clinically important enough to be documented in their medical charts within 48 hours of CDAD diagnosis, despite the fact that all of them had unformed stool samples collected for C. difficile toxin testing.…”

“…2 In this letter, we provide a Table that details how the CTCAE are used in our grading system. Many of the signs and symptoms mentioned by Jaber et al 1 are part of the CTCAE for colitis. Grade 2 colitis includes abdominal pain and mucus or blood in stool.…”

“…-W e appreciate the comments of Jaber et al 1 regarding our Clostridium difficile-associated disease (CDAD) severity grading system. 2 We agree that although diarrhea is the hallmark symptom of CDAD, a comprehensive CDAD severity grading system must also incorporate many of the symptoms that Jaber et al 1 mention.…”

“…In addition to these symptoms and those listed in the CTCAE for diarrhea, we added hypothermia. The nature of our study population (ie, allogeneic hematopoietic stem cell transplant recipients) precludes the use of several of the other severity criteria mentioned by Jaber et al 1 Many of the patients were neutropenic, making white blood cell counts frequently inapplicable. All of the subjects were immunosuppressed, and therefore immunosuppression is not a useful criterion for assessing the risk of poor outcomes due to CD AD in this patient population.…”

“…Previous CDAD severity grading systems, including those mentioned by Jaber et al, 1 were not limited to symptoms present early in a patient's clinical course. Pepin et al 4 included death within 30 days of diagnosis in their definition of a complicated CDAD case.…”