Lack of adherence to SHEA-IDSA treatment guidelines for Clostridium difficile infection is associated with increased mortality

Abstract

Objectives: The objective of this study was to determine our institution's compliance with 2010 Society for Healthcare Epidemiology of America and IDSA Clostridium difficile infection (CDI) treatment guidelines and their respective outcomes.

Methods: We collected clinical parameters, laboratory values, antibiotic therapy and clinical outcomes from the electronic medical records for all patients hospitalized at our institution with a diagnosis of CDI from December 2012 to November 2013. We specifically evaluated whether SHEA-IDSA treatment guidelines were followed and evaluated the associations between guideline adherence and severe outcomes including mortality.

Results: We identified 230 patients with CDI meeting inclusion criteria during the study period. Of these, 124 (54%) were appropriately treated, 46 (20%) were under-treated and 60 (26%) were over-treated. All-cause 90 day mortality was 17.4% overall; 43.5% in the under-treated group versus 12.9% in those appropriately treated (P < 0.0001) and 10.9% in those appropriately treated plus over-treated (P < 0.0001). Similarly, 90 day mortality attributed to CDI was 21.7% in those under-treated versus 8.9% in those appropriately treated (P = 0.03) and 8.2% in those either appropriately treated or over-treated (P = 0.015). Severe-complicated CDI occurred in 46 patients. In this subgroup, there was a non-significant trend towards increased mortality in under-treated patients (56.7%) compared with appropriately treated patients (37.5%, P = 0.35). Under-treatment was also associated with a higher rate of CDI-related ICU transfer (17.4% versus 4.8% in those appropriately treated, P = 0.023).

Conclusions: Adherence to CDI treatment guidelines is associated with improved outcomes especially in those with severe disease. Increased emphasis on provision of appropriate, guideline-based CDI treatment appears warranted.

Figure 1.

All-cause 90 day mortality rate was 17.4% overall (40 of 230 patients). It was 43.5% (20 of 46) in the under-treated group, 12.9% (16 of 124) in the appropriately treated group and 6.7% (4 of 60) in the over-treated group.

Figure 2.

CDI-related 90 day mortality rate was 10.9% overall (25 of 230 patients). It was 21.7% (10 of 46) in the under-treated group, 8.9% (11 of 124) in the appropriately treated group and 6.7% (4 of 60) in the over-treated group.

Figure 3.

CDI-related ICU transfer rate was 6.5% overall (15 of 230 patients). It was 17.4% (8 of 46) in the under-treated group, 4.8% (6 of 124) in the appropriately treated group and 1.7% (1 of 60) in the over-treated group.