Predictors of Mortality Among a National Cohort of Veterans With Recurrent Clostridium difficile Infection

Appaneal, Haley J; Caffrey, Aisling R.; Beganovic, Maya; Avramovic, Sanja; LaPlante, Kerry L.

doi:10.1093/ofid/ofy175

Cited by 24 publications

(32 citation statements)

References 53 publications

(76 reference statements)

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“…We also noted an association with chronic kidney disease and increased mortality which has also been reported previously, particularly in patients with end-stage renal disease and patients on dialysis, compared to the general population [ 34 , 35 ]. Diabetes is also a predisposing factor for CDI development and recurrence [ 36 , 37 ], but it was not shown to be a mortality-related factor [ 20 , 25 , 27 ]. In our study diabetes was more prevalent in the deceased group, but it was not independent death predictor, when assessed in the multivariate logistic regression model.…”

Section: Discussionmentioning

confidence: 99%

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Mortality Following Clostridioides difficile Infection in Europe: A Retrospective Multicenter Case-Control Study

et al. 2021

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We aimed to describe the clinical presentation, treatment, outcome and report on factors associated with mortality over a 90-day period in Clostridioides difficile infection (CDI). Descriptive, univariate, and multivariate regression analyses were performed on data collected in a retrospective case-control study conducted in nine hospitals from seven European countries. A total of 624 patients were included, of which 415 were deceased (cases) and 209 were still alive 90 days after a CDI diagnosis (controls). The most common antibiotics used previously in both groups were β-lactams; previous exposure to fluoroquinolones was significantly (p = 0.0004) greater in deceased patients. Multivariate logistic regression showed that the factors independently related with death during CDI were older age, inadequate CDI therapy, cachexia, malignancy, Charlson Index, long-term care, elevated white blood cell count (WBC), C-reactive protein (CRP), bacteraemia, complications, and cognitive impairment. In addition, older age, higher levels of WBC, neutrophil, CRP or creatinine, the presence of malignancy, cognitive impairment, and complications were strongly correlated with shortening the time from CDI diagnosis to death. CDI prevention should be primarily focused on hospitalised elderly people receiving antibiotics. WBC, neutrophil count, CRP, creatinine, albumin and lactate levels should be tested in every hospitalised patient treated for CDI to assess the risk of a fatal outcome.

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Section: Discussionmentioning

confidence: 99%

“…CDI is a recognised problem in LTC facilities; residents are often elderly with multiple co-morbidities. LTC admission 90 days before CDI was related with 30-day all-cause mortality in one study [ 27 ]. We also found that previous LTC residency was more prevalent in the deceased group and was independently associated with a fatal outcome.…”

Section: Discussionmentioning

confidence: 99%

Mortality Following Clostridioides difficile Infection in Europe: A Retrospective Multicenter Case-Control Study

et al. 2021

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“…We validated our simulation model by comparing the shortterm model-predicted mortality to that observed in large CDI patient cohorts [12,[19][20][21]. Our average 60-day mortality for all 48 strategies was 8%, whereas many studies report 30-day mortality of 9%-10%.…”

Section: Model Validationmentioning

confidence: 92%

Cost-effectiveness of Treatment Regimens for Clostridioides difficile Infection: An Evaluation of the 2018 Infectious Diseases Society of America Guidelines

Rajasingham

Enns

Khoruts

et al. 2019

Clinical Infectious Diseases

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Background In 2018, the Infectious Diseases Society of America (IDSA) published guidelines for diagnosis and treatment of Clostridioides (formerly Clostridium) difficile infection (CDI). However, there is little guidance regarding which treatments are cost-effective. Methods We used a Markov model to simulate a cohort of patients presenting with an initial CDI diagnosis. We used the model to estimate the costs, effectiveness, and cost-effectiveness of different CDI treatment regimens recommended in the recently published 2018 IDSA guidelines. The model includes stratification by the severity of the initial infection, and subsequent likelihood of cure, recurrence, mortality, and outcomes of subsequent recurrences. Data sources were taken from IDSA guidelines and published literature on treatment outcomes. Outcome measures were discounted quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Results Use of fidaxomicin for nonsevere initial CDI, vancomycin for severe CDI, fidaxomicin for first recurrence, and fecal microbiota transplantation (FMT) for subsequent recurrence (strategy 44) cost an additional $478 for 0.009 QALYs gained per CDI patient, resulting in an ICER of $31 751 per QALY, below the willingness-to-pay threshold of $100 000/QALY. This is the optimal, cost-effective CDI treatment strategy. Conclusions Metronidazole is suboptimal for nonsevere CDI as it is less beneficial than alternative strategies. The preferred treatment regimen is fidaxomicin for nonsevere CDI, vancomycin for severe CDI, fidaxomicin for first recurrence, and FMT for subsequent recurrence. The most effective treatments, with highest cure rates, are also cost-effective due to averted mortality, utility loss, and costs of rehospitalization and/or further treatments for recurrent CDI.

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“…Similar to previous findings, a principal diagnosis of CDI (as compared to those hospitalized without a principal diagnosis of CDI or outpatients) was identified as a significant predictor of failure likely related to CDI severity. [9,27,28] Previous hospital or long-term care exposure was also a predictor of poor outcomes. The association between CDI and exposure to healthcare settings is well recognized.…”

Section: Discussionmentioning

confidence: 99%

“…A cohort of Veterans with a first CDI episode (defined as a stool sample positive for C. difficile toxin(s) and > 2 days of CDI treatment) from May 1, 2010 to December 30, 2014 was used. [9] CDI episodes from inpatient and outpatient settings from 125 VA centers nationally were included. Only patients with mild disease (defined as a white blood cell count (WBC) <15 x 10 3 /μL and a serum creatinine (SCr) was <1.5 mg/dL within 7 days of CDI treatment) and those treated per guidelines (10-14 days of monotherapy with oral metronidazole or oral vancomycin) were included.…”

Section: Study Populationmentioning

confidence: 99%

What Is the Role for Metronidazole in the Treatment of Clostridium difficile Infection? Results From a National Cohort Study of Veterans With Initial Mild Disease

Appaneal

Caffrey

LaPlante

2018

Clinical Infectious Diseases

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Background Metronidazole may still be an appropriate therapeutic option for mild Clostridium difficile infection (CDI) in select patients, but data are limited to guide clinicians in identifying these patients. Methods Our 2-stage study included a national cohort of Veterans with a first episode of mild CDI (2010–2014). First, among those treated with metronidazole, we identified predictors of success, defined as absence of all-cause mortality or recurrence 30 days posttreatment, using multivariable unconditional logistic regression. Second, among a subgroup of patients with characteristics predictive of success identified in the first stage, we compared clinical outcomes among those treated with metronidazole compared with vancomycin, using Cox proportional hazards models for time to 30-day all-cause mortality, CDI recurrence, and failure. Results Among 3656 patients treated with metronidazole, we identified 3282 patients with success and 374 patients without success (failure). Younger age was the only independent predictor of success. Age ≤65 years was associated with an odds of success 1.63 times higher (95% confidence interval [CI], 1.29–2.06) than age >65 years. Among 115 propensity score–matched pairs ≤65 years of age, no significant differences were observed between metronidazole and vancomycin (reference) for all-cause mortality (hazard ratio [HR], 0.29 [95% CI, .06–1.38]), CDI recurrence (HR, 0.62 [95% CI, .26–1.49]), or failure (HR, 0.50 [95% CI, .23–1.07]). Conclusions Among patients ≤65 years of age with initial mild CDI, clinical outcomes were similar with metronidazole and vancomycin. These data suggest that metronidazole may be considered for the treatment of initial mild CDI among patients 65 years of age or younger.

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Predictors of Mortality Among a National Cohort of Veterans With Recurrent Clostridium difficile Infection

Cited by 24 publications

References 53 publications

Mortality Following Clostridioides difficile Infection in Europe: A Retrospective Multicenter Case-Control Study

Mortality Following Clostridioides difficile Infection in Europe: A Retrospective Multicenter Case-Control Study

Cost-effectiveness of Treatment Regimens for Clostridioides difficile Infection: An Evaluation of the 2018 Infectious Diseases Society of America Guidelines

What Is the Role for Metronidazole in the Treatment of Clostridium difficile Infection? Results From a National Cohort Study of Veterans With Initial Mild Disease

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