Hostname: page-component-78c5997874-g7gxr Total loading time: 0 Render date: 2024-11-05T08:08:26.057Z Has data issue: false hasContentIssue false
  • English
  • Français

Underlying Disease Severity as a Major Risk Factor for Nosocomial Clostridium difficile Diarrhea

Published online by Cambridge University Press:  02 January 2015

Lorraine Kyne ,
Stavros Sougioultzis ,
Lynne V. McFarland  and
Ciarán P. Kelly
Lorraine Kyne*
Affiliation:
Gerontology Division, Beth Israel Deaconess Medical Center, andHarvard Medical School, Boston, Massachusetts
Stavros Sougioultzis
Affiliation:
Gastroenterology Division, Beth Israel Deaconess Medical Center, andHarvard Medical School, Boston, Massachusetts
Lynne V. McFarland
Affiliation:
Department of Health Services, School of Public Health & Community Medicine, University of Washington, Seattle, Washington
Ciarán P. Kelly
Affiliation:
Gastroenterology Division, Beth Israel Deaconess Medical Center, andHarvard Medical School, Boston, Massachusetts
*
Gerontology Division, Rabb 440, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

To determine the diagnostic accuracy of an index of underlying disease severity (Horn's index) in identifying patients with a high probability of having nosocomial Clostridium difficile diarrhea as a complication of antimicrobial therapy.

Design:

A prospective cohort study of 252 adult patients admitted to the hospital and receiving antibiotics. Risk factors for C. difficile diarrhea were first determined retrospectively in a different cohort of 300 hospitalized patients (primary cobort) and then prospectively in this cohort of 252 hospitalized patients receiving antibiotics (secondary cohort). At the time of hospital admission, disease was rated by clinicians as mild (1), moderate (2), severe (3), or extremely severe (4) using a modified Horn's index. Multivariable logistic regression analysis was used to determine the odds ratio (OR) for C. difficile diarrhea associated with increasing levels of disease severity.

Setting:

An urban teaching hospital affiliated with a medical school in Boston, Massachusetts.

Results:

The incidence of nosocomial C. difficile diarrhea was 8.7% in the primary cohort and 11% in the secondary cohort. In the prospective cohort study (secondary cohort), the OR for C. difficile diarrhea associated with extremely severe disease was 17.6 (95% confidence interval, 5.8 to 53.5). The sensitivity, specificity, and positive and negative predictive values of a Horn's index score of 3 or more (severe to extremely severe disease) as a predictor of nosocomial C. difficile diarrhea were 79%, 73%, 27%, and 96%, respectively.

Conclusions:

These findings provide a means of early stratification of hospitalized patients receiving antibiotics according to their risk for nosocomial C. difficile diarrhea. Patients with severe to extremely severe disease at the time of admission may benefit from careful monitoring of antibiotic prescribing and early attention to infection control issues. In the future, these “high-risk” patients may benefit from prophylaxis studies of novel agents being developed to prevent C. difficile diarrhea.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 23 , Issue 11 , November 2002 , pp. 653 - 659
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2002

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.)

References

1.Kelly, CP, Pothoulakis, C, LaMont, JT. Clostridium difficile colitis. N Engl J Med 1994;330:257–262.Google Scholar
2.McFarland, LV. Epidemiology of infectious and iatrogenic nosocomial diarrhea in a cohort of general medicine patients. Am J Infect Control 1995;23:295–305.CrossRefGoogle Scholar
3.Kyne, L, Hamel, MB, Polavaram, R, Kelly, CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis 2002;34:346–353.CrossRefGoogle ScholarPubMed
4.Centers for Disease Control and Prevention. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). Am J Infect Control 1995;23:87–94.Google Scholar
5.McFarland, LV, Surawicz, CM, Rubin, M, Fekety, R, Elmer, GW, Greenberg, RN. Recurrent Clostridium difficile disease: epidemiology and clinical characteristics. Infect Control Hosp Epidemiol 1999;20(1):43–50.Google Scholar
6.Kyne, L, Kelly, CP. Recurrent Clostridium difficile diarrhoea. Gut 2001;49:152–153.Google Scholar
7.Spencer, RC. The role of antimicrobial agents in the aetiology of Clostridium difficile-associated disease. J Antimicrob Chemother 1998; 41(suppl C):21–27.CrossRefGoogle ScholarPubMed
8.Brown, E, Talbot, GH, Axelrod, P, Provencher, M, Hoegg, C. Risk factors for Clostridium difficile toxin-associated diarrhea. Infect Control Hosp Epidemiol 1990;11:283–290.CrossRefGoogle ScholarPubMed
9.Bliss, DZ, Johnson, S, Savik, K, Clabots, CR, Willard, K, Gerding, DN. Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding. Ann Intern Med 1998;129:1012–1019.CrossRefGoogle ScholarPubMed
10.Bignardi, GE. Risk factors for Clostridium difficile infection. J Hosp Infect 1998;40:1–15.Google Scholar
11.McFarland, LV, Surawicz, CM, Stamm, WE. Risk factors for Clostridium difficile carriage and C. dificile-associated diarrhea in a cohort of hospitalized patients. J Infect Dis 1990;162:678–684.Google Scholar
12.Horn, SD. Measuring severity of illness: comparisons across institutions. Am J Public Health 1983;73:25–31.Google Scholar
13.Horn, SD, Sharkey, PD, Bertram, DA. Measuring severity of illness: homogeneous case mix groups. Med Care 1983;21:14–30.Google Scholar
14.Horn, SD, Chachich, B, Clopton, C. Measuring severity of illness: a reliability study. Med Care 1983;21:705–714.Google Scholar
15.Owens, WD, Felts, JA, Spitznage, EL Jr. ASA physical status classifications: a study of consistency of ratings. Anesthesiology 1978;49:239–243.CrossRefGoogle ScholarPubMed
16.Kyne, L, Warny, M, Qamar, A, Kelly, CP. Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med 2000;342:390–397.Google Scholar
17.Killip, T 3rd, Kimball, JT. Treatment of myocardial infarction in a coronary care unit: a two year experience with 250 patients. Am J Cardiol 1967;20:457–464.Google Scholar
18.Charlson, ME, Sax, FL, MacKenzie, CR, Fields, SD, Braham, RL, Douglas, RG Jr. Assessing illness severity: does clinical judgment work? J Chronic Dis 1986;39:439–452.CrossRefGoogle ScholarPubMed
19.Charlson, ME, Pompei, P, Ales, KL, MacKenzie, CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.Google Scholar
20.McFarland, LV, Mulligan, ME, Kwok, RY, Stamm, WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204–210.Google Scholar
21.Hanley, JA, McNeil, BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982;143:29–36.CrossRefGoogle Scholar
22.Metz, CE. Basic principles of ROC analysis. Semin Nucl Med 1978;8:283–298.CrossRefGoogle ScholarPubMed
23.Katz, DA, Lynch, ME, Littenberg, B. Clinical prediction rules to optimize cytotoxin testing for Clostridium difficile in hospitalized patients with diarrhea. Am J Med 1996;100:487–495.CrossRefGoogle ScholarPubMed
24.Katz, DABates, DW, Rittenberg, E, et al. Predicting Clostridium difficile stool cytotoxin results in hospitalized patients with diarrhea. J Gen Intern Med 1997;12:57–62.Google Scholar
25.Nelson, DE, Auerbach, SB, Baltch, AL, et al. Epidemic Clostridium difficile-associated diarrhea: role of second- and third-generation cephalosporins. Infect Control Hosp Epidemiol 1994;15:88–94.Google Scholar
26.Tacconelli, E, Mazzella, P, Tumbarello, M. Clostridium difficile associated diarrhea: two years of observation in a University Hospital. L'Igiene Moderna 1994;102:95–104.Google Scholar
27.Wilcox, MH. Cleaning up Clostridium difficile infection. Lancet 1996; 348:767–768.CrossRefGoogle ScholarPubMed
28.Samore, MH. Epidemiology of nosocomial Clostridium difficile diarrhoea. J Hosp Infect 1999;43(suppl):S183–S190.CrossRefGoogle ScholarPubMed
29.Kyne, L, Farrell, RJ, Kelly, CP. Clostridium difficile. Gastroenterol Clin North Am 2001;30:753–777.Google Scholar
30.Worsley, MA. Infection control and prevention of Clostridium difficile infection. J Antimicrob Chemother 1998;41 (suppl C):59–66.CrossRefGoogle ScholarPubMed
31.Pear, SM, Williamson, TH, Bettin, KM, Gerding, DN, Galgiani, JN. Decrease in nosocomial Clostridium difficile-associated diarrhea by restricting clindamycin use. Ann Intern Med 1994;120:272–277.CrossRefGoogle ScholarPubMed
32.Climo, MW, Israel, DS, Wong, ES, Williams, D, Coudron, P, Markowitz, SM. Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost. Ann Intern Med 1998; 128(12 Part 1):989–995.Google Scholar
33.McNulty, C, Logan, M, Donald, IP, et al. Successful control of Clostridium difficile infection in an elderly care unit through use of a restrictive antibiotic policy. J Antimicrob Chemother 1997;40:707–711.Google Scholar
34.Surawicz, CM, Elmer, GW, Speelman, P, McFarland, LV, Chinn, J, van Belle, G. Prevention of antibiotic-associated diarrhea by Saccharomyces boulardii: a prospective study. Gastroenterology 1989;96:981–988.CrossRefGoogle ScholarPubMed
35.Gorbach, SL, Chang, TW, Goldin, B. Successful treatment of relapsing Clostridium difficile colitis with Lactobacillus GG. Lancet 1987;2:1519.Google Scholar
36.McFarland, LV, Surawicz, CM, Greenberg, RN, et al. A randomized placebo-controlled trial of Saccharomyces boulardii in combination with standard antibiotics for Clostridium difficile disease. JAMA 1994;271:1913–1918.Google Scholar
37.Surawicz, CM, McFarland, LV, Greenberg, RN, et al. The search for a better treatment for recurrent Clostridium difficile disease: use of high-dose vancomycin combined with Saccharomyces boulardii. Clin Infect Dis 2000;31:1012–1017.Google Scholar
38.Heerze, LD, Keim, MA, Talbot, JA, Armstrong, GD. Oligosaccharide sequences attached to an inert support (SYNSORB) as potential therapy for antibiotic-associated diarrhea and pseudomembranous colitis. J Infect Dis 1994;169:1291–1296.CrossRefGoogle Scholar
39.Castagliuolo, I, LaMont, JT, Qiu, B, Nikulasson, ST, Pothoulakis, C. A receptor decoy inhibits the enterotoxic effects of Clostridium difficile toxin A in rat ileum. Gastroenterology 1996;111:433–438.Google Scholar
40.Kyne, L, Kelly, C. Prospects for a vaccine for Clostridium difficile. BioDrugs 1998;10:173–181.Google Scholar