C. difficile colitis--predictors of fatal outcome

Abstract

Purpose: Clostridium difficile colitis (CDC) has a clinical spectrum ranging from mild diarrhea to fulminant, potentially fatal colitis. The pathophysiology for this variation remains poorly understood. A total abdominal colectomy may be lifesaving if performed before the point of no return. Identification of negative prognostic factors is desperately needed for optimization of the clinical and operative management.

Methods: In-patients with CDC between 1999 and 2006 were identified through the discharge database (ICD-9: 008.45). Of these, patients with positive ELISA toxin or biopsy were included. Excluded were ELISA-negative patients. Data collected included general demographics, underlying medical conditions, APACHE II score, clinical and laboratory data, and duration of the medical treatment. Mortality and cure were the two endpoints. Regression analysis was used to identify parameters associated with mortality.

Results: Three hundred ninety-eight patients (mean age 59, range 19-94) with CDC were analyzed. Fourteen patients (3.52%) underwent surgery. Mortality in the cohort was 10.3% (41/398 patients). Patients with fatal outcome had a longer pre-CDC hospital stay (11 vs. 6 days). Mortality was significantly (p<0.05) associated with a higher APACHE II score, a higher ASA class, a lower diastolic blood pressure, preexisting pulmonary and renal disease, use of steroids, evidence of toxic megacolon, higher WBCs, and clinical signs of sepsis and organ dysfunction (renal and pulmonary). Parameters without significant difference (p>0.05) included patient age, albumin, clinical presentation/examination parameters, and transplant status, other than the mentioned comorbidities. Of the 41 fatal outcomes, five patients (12.2%) underwent surgery, and 36 did not (87.8%). Mortality rate of the surgical group was 35.7% (four out of 14 patients). Comparison of the fatalities not undergoing surgery with the survivors revealed decreased clinical signs, suggesting a masking of the disease severity.

Conclusions: Our study identified several clinical factors, which were associated with mortality from CDC. Future clinical studies will have to focus on the disease progression and the fatalities occurring either without an attempt for or despite surgical intervention, as an earlier intervention might have proven lifesaving.