Hostname: page-component-586b7cd67f-rdxmf Total loading time: 0 Render date: 2024-11-24T23:56:31.389Z Has data issue: false hasContentIssue false
  • English
  • Français

Clostridium difficile Recurrence Is a Strong Predictor of 30-Day Rehospitalization Among Patients in Intensive Care

Published online by Cambridge University Press:  22 December 2014

Marya D. Zilberberg ,
Andrew F. Shorr ,
Scott T. Micek  and
Marin H. Kollef
Marya D. Zilberberg*
Affiliation:
EviMed Research Group, LLC, Goshen, MA School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA
Andrew F. Shorr
Affiliation:
Washington Hospital Center, Washington, DC
Scott T. Micek
Affiliation:
St. Louis College of Pharmacy, St. Louis, MO
Marin H. Kollef
Affiliation:
Barnes-Jewish Hospital, St. Louis, MO.
*
Address correspondence to Marya Zilberberg, MD, MPH, EviMed Research Group, LLC, PO Box 303, Goshen, MA 01032 (evimedgroup@gmail.com).
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective

While incidence, mortality, morbidity, and recurrence rates of C. difficile infection (CDI) among the critically ill have been investigated, the impact of its recurrence on 30-day rehospitalization (ReAd), an important policy focus, has not been examined.

Design

Secondary analysis of a multicenter retrospective cohort study

Patients

Adult critically ill patients who survived their index hospitalization complicated by CDI

Methods

CDI was defined by diarrhea or pseudomembranous colitis and a positive assay for C. difficile toxins A and/or B. CDI recurrence (rCDI) was defined as diarrhea, positive C. difficile toxin and need for retreatment after cessation of therapy. Descriptive statistics and a logistic regression examined ReAd rates and characteristics, and factors that impact it.

Results

Among 287 hospital survivors, 76 (26.5%) required ReAd (ReAd+). At baseline, the ReAd+ group did not differ significantly from the ReAd– group based on demographics, comorbidities, APACHE II scores, or ICU type. ReAd+ patients were more likely to have hypotension at CDI onset (48.7% vs 34.1%, P=.025) and to require vasopressors (40.0% vs 27.1%, P=.038); they were less likely to require mechanical ventilation (56.0% vs 77.3%, P<.001). A far greater proportion of ReAd+ than ReAd– had developed a recurrence either during the index hospitalization or within 30 days after discharge (32.89% vs 2.84%, P<.001). In a logistic regression, rCDI was a strong predictor of ReAd+ (adjusted odd ratio, 15.33, 95% confidence interval, 5.68–41.40).

Conclusions

Greater than 25% of all survivors of critical illness complicated by CDI require readmission within 30 days of discharge. CDI recurrence is a strong predictor of such rehospitalizations.

Infect Control Hosp Epidemiol 2014;00(0): 1–7

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 36 , Issue 3 , March 2015 , pp. 273 - 279
Copyright
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

Presentation: These data have been accepted for presentation at the annual ID Week 2014 in Philadelphia, PA.

References

1.Compare your country—health profile. United States Organization for Economic Cooperation and Development website. http://www.compareyourcountry.org/health/health-spending-gdp?cr=oecd&lg=en. Accessed April 16, 2014.Google Scholar
2.Institute of Medicine. To Err is Human: Building a Safer Health System (Washington: National Academies Press, 1999).Google Scholar
3.Zimlichman, E, Henderson, D, TamirO, PhD O, PhD, Franz, C, Song, P, Yamin, C, Keohane, C, Denham, CR, Bates, DW. Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:2039–2046.Google Scholar
4.Readmission reduction program. Centers for Medicare and Medicaid Services, Department of Health and Human Services website. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed April 14, 2014.Google Scholar
5.Magill, SS, Edwards, JR, Wendy Bamberg, W, et al. for the Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:1198–1208.CrossRefGoogle ScholarPubMed
6.Dubberke, ER, Olsen, MA. Burden of Clostridium difficile on the Healthcare System. Clin Infect Dis 2012;55:S88–S92.CrossRefGoogle ScholarPubMed
7.Pépin, JL, Valiquette, L, Abary, ME, Villemure, P, Pelletier, A, Forget, K, Pépin, K, Chouinard, D. Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ 2004;171:466–472.Google Scholar
8.Muto, CA, Blank, MK, Marsh, JW, et al. Control of an outbreak of infection with the hypervirulent Clostridium difficile BI strain in a university hospital using a comprehensive “bundle” approach. Clin Infect Dis 2007;45:1266–1273.Google Scholar
9.McDonald, LC, Owings, M, Jernigan, DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996–2003. Emerg Infect Dis 2006;12:409–415.Google Scholar
10.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.Google Scholar
11.McDonald, LC, Killgore, GE, Thompson, A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005;353:2433–2441.CrossRefGoogle ScholarPubMed
12.Hudson, M. Statistical bulletin—deaths involving Clostridium difficile: England & Wales 2009. Newport, Wales: Office for National Statistics, 2010.Google Scholar
13.Loo, VG, Poirier, L, Miller, MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:2442–2449.CrossRefGoogle ScholarPubMed
14.Hubert, B, Loo, VG, Bourgault, AM, et al. A portrait of the geographic dissemination of the Clostridium difficile North American pulsed-field type 1 strain and the epidemiology of C. difficile-associated disease in Quebec. Clin Infect Dis 2007;44:238–244.Google Scholar
15.Zilberberg, MD, Nathanson, BH, Sadigov, S, et al. Epidemiology and outcomes of Clostridium difficile-associated disease among patients on prolonged acute mechanical ventilation. Chest 2009;136:752–758.Google Scholar
16.Micek, ST, Schramm, G, Morrow, L, et al. Clostridium difficile infection: a multicenter study of epidemiology and outcomes in mechanically ventilated patients. Crit Care Med 2013;41:1968–1975.Google Scholar
17.Lawrence, SJ, Puzniak, LA, Shadel, BN, et al. Clostridium difficile in the intensive care unit: epidemiology, costs, and colonization pressure. Infect Control Hosp Epidemiol 2007;28:123–130.CrossRefGoogle ScholarPubMed
18.Lagu, T, Stefan, MS, Haessler, S, Higgins, TL, Rothberg, MB, Nathanson, BH, Hannon, NS, Steingrub, JS, Lindenauer, PK. The impact of hospital-onset Clostridium difficile infection on outcomes of hospitalized patients with sepsis. J Hosp Med 2014 Apr 9. DOI 10.1002/jhm.2199 [Epub ahead of print].CrossRefGoogle ScholarPubMed
19.Cohen, SH, Gerding, DN, Johnson, S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31:431–455.Google Scholar
20.Knaus, WA, Draper, EA, Wagner, DP, et al. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818–829.Google Scholar
21.Bobo, LD, Dubberke, ER, Kollef, M. Clostridium difficile in the ICU: the struggle continues. Chest 2011;140:1643–1653.Google Scholar
22.Shorr, AF, Zilberberg, MD, Reichley, R, et al. Readmission following hospitalization for pneumonia: the impact of pneumonia type and its implication for hospitals. Clin Infect Dis 2013;57:362–367.CrossRefGoogle ScholarPubMed
23.Garey, KW, Sethi, S, Yadav, Y, DuPont, HL. Meta-analysis to assess risk factors for recurrent Clostridium difficile infection. J Hosp Infect 2008;70:298–304.CrossRefGoogle ScholarPubMed
24.Fekety, R, McFarland, LV, Surawicz, CM, Greenberg, RN, Elmer, GW, Mulligan, ME. Recurrent Clostridium difficile diarrhea: characteristics of and risk factors for patients enrolled in a prospective, randomized, double-blinded trial. Clin Infect Dis 1997;24:324–333.Google Scholar
25.McFarland, LV, Surawicz, CM, Rubin, M, Fekety, R, Elmer, GW, Greenberg, RN. Recurrent Clostridium difficile: epidemiology and clinical characteristics. Infect Control Hosp Epidemiol 1999;20:43–50.Google Scholar
26.Cadle, RM, Mansouri, MD, Logan, N, Kudva, DR, Musher, DM. Association of proton-pump inhibitors with outcomes in Clostridium difficile colitis. Am J Health Syst Pharm 2007;64:2359–2363.Google Scholar
27.Kim, JW, Lee, KL, Jeong, JB, et al. Proton pump inhibitors as a risk factor for recurrence of Clostridium-difficile–associated diarrhea. World J Gastroentetol 2010;16:3573–3577.CrossRefGoogle ScholarPubMed
28.Kim, YG, Graham, DY, Jang, BI. Proton pump inhibitor use and recurrent Clostridium difficile-associated disease: a case-control analysis matched by propensity score. J Clin Gastroenterol 2012;46:397–400.Google Scholar
29.Prkno, A, Wacher, C, Brunkhorst, FM, Schlattmann, P. Procalcitonin-guided therapy in intensive care unit patients with severe sepsis and septic shock—a systematic review and meta-analysis. Critical Care 2013;17:R291.Google Scholar
30.Albrich, WC, Dusemund, F, Bucher, B, et al. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in “real life”: an international, multicenter poststudy survey (proreal). Arch Intern Med 2012;172:715–722.Google ScholarPubMed
31.American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.CrossRefGoogle Scholar
32.Louie, TJ, Miller, MA, Mullane, KM, et al; OPT-80-003 Clinical Study Group. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med 2011;364:422–431.Google Scholar
33.Cornely, OA, Crook, DW, Esposito, R, et al; OPT-80-004 Clinical Study Group. Fidaxomicin versus vancomycin for infection with Clostridium difficile in Europe, Canada, and the USA: a double-blind, non-inferiority, randomised controlled trial. Lancet Infect Dis 2012;12:281–289.Google Scholar
34.Cammarota, G, Ianiro, G, Gasbarrini, A. Fecal microbiota transplantation for the treatment of Clostridium difficile infection: a systematic review. J Clin Gastroenterol 2014 Jan 16. [Epub ahead of print].CrossRefGoogle ScholarPubMed
35.Lofgren, ET, Moehring, RW, Anderson, DJ, Weber, DJ, Fefferman, NH. A mathematical model to evaluate the routine use of fecal microbiota transplantation to prevent incident and recurrent Clostridium difficile infection. Infect Control Hosp Epidemiol 2013;35:18–27.CrossRefGoogle ScholarPubMed
36.Rao, K, Young, VB, Aronoff, DM. Commentary: Fecal microbiota therapy: ready for prime time? Infect Control Hosp Epidemiol 2014;35:28–30.Google Scholar
37.Zilberberg, MD, Reske, K, Olsen, M, Yan, Y, Dubberke, ER. Development and validation of a recurrent Clostridium difficile risk-prediction model. J Hosp Med 2014;9:418–423.Google Scholar