Over the past decade, the epidemiology of Clostridium difficile infection (CDI) has shown a remarkable increase in incidence with an associated increase in severity.
Dr Paul Feuerstadt and colleagues from Connecticut, USA compared the demographics, medication exposure, evaluation, treatment patterns, and outcomes of patients with CDI in 2 different time periods, including 2006–2008 and 2009–2011.
The researchers hypothesized that mortality is decreasing with increasing appropriateness of medical management.
The team retrospectively identified consecutive patients admitted to Montefiore Medical Center between 1/1/2006 and 12/31/2011 with symptomatic diarrhea, and a positive C. difficile toxin assay.
|Factors associated with 30-day mortality include age, white blood cells, and albumin level |
|American Journal of Gastroenterology|
The cohort was subdivided into those diagnosed in 2006–2008, and 2009–2011.
The research team obtained key parameters at the time of diagnosis including demographics, medication exposure, medical comorbidities, laboratory data, CDI evaluation, and various outcome measures.
The team created a subcohort for each time frame of patients diagnosed with severe CDI defined by white blood cell count >15,000 cells/μl, and albumin <3.0 g/dl and made the same comparisons as for the overall cohort.
The resesarch team identified 4 cohorts including CDI 2006–08, CDI 2009–11, severe CDI 2006–08, and severe CDI 2009–11.
CDI 09–11 patients were older and had higher Charlson comorbidity scores than did those in the CDI 06–08 cohort.
The team observed no significant demographic differences in the severe cohort.
For both the overall and severe cohorts, there was more macrolide exposure before diagnosis with CDI, and lower rates of quinolone exposure in the more recent era.
The researchers found that the disease process also appeared less severe in the CDI 2009–11 cohort with lower peak white blood cells during admission and at diagnosis.
Treatment patterns appeared more aggressive during the more recent time frame, with shorter durations of oral metronidazole, longer durations of IV metronidazole, more frequent use of vancomycin as the sole therapy, more frequent switching from metronidazole to vancomycin, and less frequent exposure to any metronidazole throughout treatment in the overall cohort.
The researchers found that the 30-day mortality decreased significantly in both the overall, and the severe cohorts from CDI 06–08 to CDI 09–11, with mortality decreasing significantly in the 8th and 9th decades of life in the overall cohort and in the 8th, 9th, and 10th decades in the severe cohort.
Dr Feuerstadt's team concludes, "In an urban United States population, CDI 2009–11 showed changes in medication exposures, less severe disease, and more aggressive management with better outcomes and decreased mortality compared with CDI 06–08."
"The most important factors associated with 30-day mortality in both an overall and severe CDI population include age, white blood cells, and albumin level at the time of diagnosis."