Risk factors and outcomes of Clostridium difficile infection in hospitalized patients

Abstract

Background: The aim of this study was to identify risk factors for Clostridium difficile infection (CDI) and its attributable mortality and to propose methods to prevent CDI and improve patients' outcomes.

Methods: CDI was defined as diarrheal patients with stool samples that were positive for C. difficile toxin. Clinical presentations of all patients with CDI and two times as many age- and sex-matched culture-negative controls at the Chang Gung Memorial Hospital in 2014 were identified and compared by multivariate, nonparametric, and Kaplan-Meier survival analysis.

Results: There were no significant differences in ages, sex, or Charlson comorbidity indexes between the CDI group (n = 42) and the control group (n = 86). The multivariate analysis indicated that underlying peptic ulcer disease and previous use of gastric acid inhibitors or third-generation cephalosporins for at least 3 days were significantly more common in patients with CDI than in the controls. Charlson scores were associated with mortality due to CDI. Recommended treatment using oral vancomycin to treat patients with Charlson score ≥ 5 and oral metronidazole or vancomycin to treat those with moderate underlying disease (Charlson score ≥ 2 and ≤ 5) significantly increased survival in these patients (p = 0.001).

Conclusions: Oral vancomycin given to patients with high Charlson scores and oral metronidazole or vancomycin to patients with moderate Charlson scores decreased mortality due to CDI. Restricting the use of third-generation cephalosporins and gastric acid inhibitors is recommended to prevent CDI in hospitalized patients.

Keywords: Charlson score; Clostridium difficile infection; Gastric acid inhibitor; Risk factor; Third-generation cephalosporin.

Fig. 1

Kaplan–Meier survival curves of patients with Clostridium difficile infection (CDI). (A) Kaplan–Meier survival curve of patients with Charlson scores < 5 (solid line) compared with those with Charlson scores ≥ 5 (dotted line) (p = 0.002 by log-rank test). (B) Kaplan–Meier survival curve of patients without metastatic solid tumors (solid line) compared with those with metastatic solid tumors (dotted line) (p = 0.018 by log-rank test). (C) Kaplan–Meier survival curve of patients who received appropriate therapy (dotted line) compared with those who did not receive appropriate therapy (solid line) (p = 0.890 by log-rank test). (D) Kaplan–Meier survival curve of patients who received recommended treatment based on Charlson score (solid line) compared with those who did not receive such treatment (dotted line) (p = 0.001 by log-rank test).