Original Article

Predictors of 30-Day Mortality in Hospitalized Patients with Clostridium difficile Infection

Authors: Jayakrishna Chintanaboina, MD, MPH, Seyedehsan Navabi, MD, Kristen Suchniak-Mussari, MD, Benjamin Stern, DO, Simranjit Bedi, DO, Erik B. Lehman, MS, Andrew Tinsley, MD

Abstract

 Objectives: Clostridium difficile infection (CDI) is a significant cause of morbidity and mortality and is the most common nosocomial infection in the United States, with associated annual costs of approximately $3 billion. The epidemiology of CDI has changed with the identification of novel risk factors for incident and recurrent CDI. The aim of this study was to identify the predictors of 30-day mortality in hospitalized patients with CDI.

Methods: We identified all of the patients diagnosed as having CDI from January 2011 to December 2014 at our university-setting hospital. Data were extracted using electronic medical records and chart review. The data of all of the patients who died within 30 days of incident CDI were compared with those who survived beyond 30 days of incident CDI. A multivariable logistic regression model was created for mortality after finding a subset of significant predictor variables by making bivariate comparisons also using logistic regression.

Results: A total of 893 patients were diagnosed as having CDI during the study period. The mean age was 62 years and 49.5% were women. The mean length of hospital stay was 11.73 days. Of the 893 patients with CDI, 98 (10.97%) died within 30 days of incident CDI. CDI recurrence was noted in 76 patients (8.51%). On multivariate logistic regression analysis, peptic ulcer disease, advanced age, Charlson comorbidity index, and intensive care unit status were found to be significantly associated with 30-day mortality. There was no significant association between acid suppression and CDI mortality.

Conclusions: Advanced age, Charlson comorbidity index, intensive care unit status, and peptic ulcer disease are predictors of all-cause 30-day mortality in hospitalized patients with CDI.

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References

1. Miller BA, Chen LF, Sexton DJ, et al. Comparison of the burdens of hospital-onset, healthcare facility-associated Clostridium difficile infection and of healthcare-associated infection due to methicillin-resistant Staphylococcus aureus in community hospitals. Infect Control Hosp Epidemiol 2011;32:387-390.
 
2. O'Brien JA, Lahue BJ, Caro JJ, et al. The emerging infectious challenge of Clostridium difficile-associated disease in Massachusetts hospitals: clinical and economic consequences. Infect Control Hosp Epidemiol 2007;28:1219-1227.
 
3. Lucado J, Gould C, Elixhauser A. Clostridium difficile Infections (CDI) in Hospital Stays, 2009. Healthcare Cost and Utilization Project statistical brief no. 124. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality, 2011.
 
4. Pant C, Madonia P, Minocha A. Does PPI therapy predispose to Clostridium difficile infection?. Nat Rev Gastroenterol Hepatol 2009;6:555-557.
 
5. Kyne L, Sougioultzis S, McFarland LV, et al. Underlying disease severity as a major risk factor for nosocomial Clostridium difficile diarrhea. Infect Control Hosp Epidemiol 2002;23:653-659.
 
6. Owens RC, Jr Donskey CJ, Gaynes RP, et al. Antimicrobial-associated risk factors for Clostridium difficile infection. Clin Infect Dis 2008;46(Suppl 1):S19-S31.
 
7. Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012;143:1179-87. e1-e3.
 
8. Leibovici-Weissman Y, Atamna A, Schlesinger A, et al. Risk factors for short- and long-term mortality in very old patients with Clostridium difficile infection: a retrospective study. Geriatr Gerontol Int 2016; [Epub ahead of print].
9. Drozd EM, Inocencio TJ, Braithwaite S, et al. Mortality, hospital costs, payments, and readmissions associated with Clostridium difficile infection among Medicare beneficiaries. Infect Dis Clin Pract (Baltim Md) 2015;23:318-323.
 
10. Pepin J, Valiquette L, Cossette B. Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec. CMAJ 2005;173:1037-1042.
 
11. Redelings MD, Sorvillo F, Mascola L. Increase in Clostridium difficile-related mortality rates, United States, 1999-2004. Emerg Infect Dis 2007;13:1417-1419.
 
12. Zilberberg MD, Shorr AF, Kollef MH. Increase in adult Clostridium difficile-related hospitalizations and case-fatality rate, United States, 2000-2005. Emerg Infect Dis 2008;14:929-931.
 
13. Bartlett JG, Moon N, Chang TW, et al. Role of Clostridium difficile in antibiotic-associated pseudomembranous colitis. Gastroenterology 1978;75:778-782.
 
14. Miller M, Gravel D, Mulvey M, et al. Health care-associated Clostridium difficile infection in Canada: patient age and infecting strain type are highly predictive of severe outcome and mortality. Clin Infect Dis 2010;50:194-201.
 
15. Cadena J, Thompson GR, 3rd Patterson JE, et al. Clinical predictors and risk factors for relapsing Clostridium difficile infection. Am J Med Sci 2010;339:350-355.
 
16. Shears P, Prtak L, Duckworth R. Hospital-based epidemiology: a strategy for 'dealing with Clostridium difficile. J Hosp Infect 2010;74:319-325.
 
17. Fenner L, Frei R, Gregory M, et al. Epidemiology of Clostridium difficile-associated disease at University Hospital Basel including molecular characterisation of the isolates 2006-2007. Eur J Clin Microbiol Infect Dis 2008;27:1201-1207.
 
18. Mitchell BG, Gardner A. Mortality and Clostridium difficile infection: a review. Antimicrob Resist Infect Control 2012;1:20.
 
19. Kenneally C, Rosini JM, Skrupky LP, et al. Analysis of 30-day mortality for Clostridium difficile-associated disease in the ICU setting. Chest 2007;132:418-424.
 
20. Khanafer N, Toure A, Chambrier C, et al. Predictors of Clostridium difficile infection severity in patients hospitalised in medical intensive care. World J Gastroenterol 2013;19:8034-8041.
 
21. Suissa D, Delaney JA, Dial S, et al. Non-steroidal anti-inflammatory drugs and the risk of Clostridium difficile-associated disease. Br J Clin Pharmacol 2012;74:370-375.
 
22. Permpalung N, Upala S, Sanguankeo A, et al. Association between NSAIDs and Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Can J Gastroenterol Hepatol 2016;2016:7431838.
 
23. McDonald EG, Milligan J, Frenette C, et al. Continuous proton pump inhibitor therapy and the associated risk of recurrent Clostridium difficile infection. JAMA Intern Med 2015;175:784-791.
 
24. Freedberg DE, Salmasian H, Friedman C, et al. Proton pump inhibitors and risk for recurrent Clostridium difficile infection among inpatients. Am J Gastroenterol 2013;108:1794-801.
 
25. Roughead EE, Chan EW, Choi NK, et al. Proton pump inhibitors and risk of Clostridium difficile infection: a multi-country study using sequence symmetry analysis. Expert Opin Drug Saf 2016;15:1589-1595.