Evaluation of advanced age as a risk factor for severe Clostridium difficile infection

Development of a Prediction Model to Identify the Risk of Clostridioides difficile Infection in Hospitalized Patients Receiving at Least One Dose of Antibiotics

OBJECTIVE

This study's objective was to develop a risk-prediction model to identify hospitalized patients at risk of Clostridioides difficile infection (CDI) who had received at least one dose of systemic antibiotics in a large tertiary hospital.

PATIENTS AND METHODS

This was a retrospective case-control study that included patients hospitalized for more than 2 days who received antibiotic therapy during hospitalization. The study included two groups: patients diagnosed with hospital CDI and controls without hospital CDI. Cases were matched 1:3 with assigned controls by age and sex. Descriptive statistics were used to identify the study population by comparing cases with controls. Continuous variables were stated as the means and standard deviations. A multivariate analysis was built to identify the significantly associated covariates between cases and controls for CDI.

RESULTS

A total of 364 patients were included and distributed between the two groups. The control group included 273 patients, and the case group included 91 patients. The risk factors for CDI were investigated, with only significant risks identified and included in the risk assessment model: age older than 70 years (p = 0.034), chronic kidney disease (p = 0.043), solid organ transplantation (p = 0.021), and lymphoma or leukemia (p = 0.019). A risk score of ≥2 showed the best sensitivity, specificity, and accuracy of 78.02%, 45.42%, and 78.02, respectively, with an area under the curve of 0.6172.

CONCLUSION

We identified four associated risk factors in the risk-prediction model. The tool showed good discrimination that might help predict, identify, and evaluate hospitalized patients at risk of developing CDI.

Frailty level at discharge predicts mortality in older patients with Clostridioides difficile more accurately than age or disease severity

PURPOSE

Clostridioides difficile infection (CDI) has a high mortality among older patients. Identification of older patients with CDI in increased mortality risk is important to target treatment and thereby reduce mortality. The aim of this study was to investigate mortality rates and compare frailty levels at discharge, measured by the record-based Multidimensional Prognostic Index (MPI), with age and severity of CDI as mortality predictors in patients with CDI diagnosed during hospitalisation.

METHODS

This was a population-based cohort study from Central Denmark Region, Denmark, including all patients  ≥ 60 years with a positive CD toxin test without prior infection and diagnosed from 1 January to 31 December 2018. Frailty level, estimated from the electronic medical record, was defined as low, moderate, or severe frailty. CDI severity was graded according to international guidelines. Primary outcome was 90-day mortality.

RESULTS

We included 457 patients with median age 77 years (interquartile range 69-84) and females (49%). Overall, 90-day mortality was 28%, and this was associated with age (hazard ratio (HR): 2.71 (95% confidence interval 1.64-4.47)), CDI severity (HR 4.58 (3.04-6.88)) and frailty (HR 10.15 (4.06-25.36)). Frailty was a better predictor of 90-day mortality than both age (p < 0.001) and CDI severity (p = 0.04) with a receiver operating characteristic curve area of 77%.

CONCLUSION

The 90-day mortality among older patients with CDI in a Danish region is 28%. Frailty measured by record-based MPI at discharge outperforms age and disease severity markers in predicting mortality in older patients with CDI.

Risk factors and clinical outcomes for Clostridioides difficile infections in a case control study at a large cancer referral center in Mexico

INTRODUCTION

Clostridioides difficile infection (CDI) is recognized as the leading cause of nosocomial diarrhea. This study describes CDI's clinical characteristics, risk factors, and outcomes in the cancer population.

METHODS

We conducted a case-control study on cancer patients from 2015-2018 at the Instituto Nacional de Cancerologia in Mexico. CDI case was defined as diarrhea episode and positive polymerase chain reaction (PCR) for toxigenic strains. Controls were cancer diagnosis-matched patients with diarrhea and negative PCR. Healthcare Facility-Onset (HO-CDI) and Community-Onset, Healthcare Facility-Associated (CO-HCFA-CDI) rates were calculated. For assessing associations, univariate and multivariate logistic regression analyses were conducted.

RESULTS

We included 148 CDI cases and 148 controls. The CDI rate was 4.1 per 10,000 patient-days and 2.1 per 1,000 patient admissions for HO-CDI and CO-HCFA-CDI episodes, respectively. Clinical characteristics associated with CDI were fever, abdominal pain, and ≥4 episodes of diarrhea/24h. Previous use of proton pump inhibitors (P=.003), fluoroquinolones (P=.016), and cephalosporins (P=.026) increased the risk for CDI acquisition, while higher age (P=.022) and male gender (P=.015) were related to severe episodes. Thirty-day all-cause mortality was higher among CDI patients (18%) than controls (9%).

CONCLUSION

The CDI rate was lower compared to other series. The incidence of CO-HCFA-CDI episodes increased, and HO-CDI cases decreased from 2016 to 2018. Risk factors for acquisition and severe infection were similar to those reported in non-cancer populations.

Can Emergency Department Wait Times Predict Rates of Hospital-Acquired Clostridioides difficile Infection? A Study of Acute Care Facilities in New York State

OBJECTIVE

Clostridioides difficile is the most common hospital-acquired pathogen and persists in the environment for extended periods. As a common entry point for patients with diarrhea, and a setting providing fast-paced, high-volume care, emergency departments (EDs) are often sites of C. difficile contamination. This study examined the relationship between average patient wait times in the ED before admission and overall hospital-acquired C. difficile infection (HA-CDI) rates in New York State acute care hospitals.

METHODS

A random-effects regression analysis compared each facility's annual average ED wait time for admitted patients with that facility's average (HA-CDI) rates for patients entering through the ED. This model controlled for known clinical and nonclinical predictors of HA-CDI: average length of stay; case mix index; total discharges, a measure of hospital size; and percent Medicare discharges, a proxy for advanced age.

RESULTS

Emergency department wait times had a significant and positive relationship with HA-CDI rates. Facilities experience an additional 0.002 cases of HA-CDI per 1000 patient discharges with every additional minute patients spend in the ED (P = 0.003), on average. Emergency department wait times also had the largest effect size (0.210), indicating that they explain more of the variance in HA-CDI rates for patients entering through the ED than some of the best-known predictors of HA-CDI.

CONCLUSIONS

The relationship between ED wait times and eventual HA-CDI warrants further exploration. These findings suggest efforts to reduce ED wait times for admitted patients or more rigorous environmental cleanliness strategies in the ED, as possible avenues for HA-CDI prevention.

European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults

SCOPE

In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults.

METHODS AND QUESTIONS

Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure.

RECOMMENDATIONS

Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.

Prognostic factors for severe and recurrent Clostridioides difficile infection: a systematic review

OBJECTIVES

Clostridioides difficile infection (CDI), its subsequent recurrences (rCDIs), and severe CDI (sCDI) provide a significant burden for both patients and the healthcare system. Identifying patients diagnosed with initial CDI who are at increased risk of developing sCDI/rCDI could lead to more cost-effective therapeutic choices. In this systematic review we aimed to identify clinical prognostic factors associated with an increased risk of developing sCDI or rCDI.

METHODS

PubMed, Embase, Emcare, Web of Science and COCHRANE Library databases were searched from database inception through March, 2021. The study eligibility criteria were cohort and case-control studies. Participants were patients ≥18 years old diagnosed with CDI, in which clinical or laboratory factors were analysed to predict sCDI/rCDI. Risk of bias was assessed by using the Quality in Prognostic Research (QUIPS) tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool modified for prognostic studies. Study selection was performed by two independent reviewers. Overview tables of prognostic factors were constructed to assess the number of studies and the respective effect direction and statistical significance of an association.

RESULTS

136 studies were included for final analysis. Greater age and the presence of multiple comorbidities were prognostic factors for sCDI. Identified risk factors for rCDI were greater age, healthcare-associated CDI, prior hospitalization, proton pump inhibitors (PPIs) started during or after CDI diagnosis, and previous rCDI.

CONCLUSIONS

Prognostic factors for sCDI and rCDI could aid clinicians to make treatment decisions based on risk stratification. We suggest that future studies use standardized definitions for sCDI/rCDI and systematically collect and report the risk factors assessed in this review, to allow for meaningful meta-analysis of risk factors using data of high-quality trials.

Can patient-reported room cleanliness measures predict hospital-acquired C. difficile infection? A study of acute care facilities in New York state

BACKGROUND

Patient experience measures, like those form the Hospital Consumer Assessment of Healthcare providers and Systems survey, are increasingly used in healthcare policy decisions. However, it remains unclear if these reflect quality of care, like rates of hospital-acquired infections (HAIs). This study examined the relationship between patient-reported room cleanliness, from the Hospital Consumer Assessment of Healthcare providers and Systems survey, and hospital-acquired C. difficile infection (HA-CDI) rates in NYS acute care hospitals.

METHODS

A random-effects regression analysis compared the percentage of patients indicating their room was "always" and "sometimes/never" kept clean to that facility's average HA-CDI rates, controlling for known predictors.

RESULTS

A higher percentage of patients reporting their room was "always" kept clean was associated with significantly lower rates of HA-CDI. Facilities experience 0.031 fewer cases of HA-CDI/1,000 discharges for every percentage point increase in the number of patients rating their room as "always" clean (P = .006). A higher percentage of patients reporting their room was "sometimes/never" kept clean was associated with higher rates of HA-CDI (β = 0.033), but this was not significant (P = .096).

CONCLUSIONS

These findings suggest patient perceptions of cleanliness may reflect microbial cleanliness and these measures could assist in the prevention of HAIs. However, further research is needed.

Laboratory markers predictive of fulminant Clostridioides difficile infection refractory to fluid resuscitation

Background

Old age, leucocytosis, hypoalbuminemia, and elevated creatinine have been identified as risk factors for fulminant Clostridioides difficile infection (CDI). High ATLAS scores have also been linked to fatal disease. The affiliated studies, however, involved patients prescribed metronidazole - a regimen no longer standard of care. The variables were thus reassessed in patients prescribed optimal therapy.

Methods

Adults hospitalized with CDI at University of Kentucky Medical Center were retrospectively reviewed. Enrolled subjects were separated according to disease classification i.e. non-severe/severe versus fulminant CDI. Fulminant patients were further subdivided into hypotensive persons responsive to fluid resuscitation, and those with sequent shock, ileus, or megacolon. Following partition, the cohorts underwent correlation analysis.

Findings

Forty-five subjects had non-severe/severe disease. Thirteen fulminant CDI patients responded to fluid resuscitation. Seventeen fulminant CDI patients developed shock, ileus, or megacolon. Median WBC counts, albumin values, and ATLAS scores varied among the cohorts. Although WBC counts were similar among the fulminant subsets, declining albumin values and increasing ATLAS scores mirrored disease worsening. Logistic regression revealed albumin values < 20 g/L (odds ratio [OR] 3.91) and ATLAS scores ≥ 6 (OR 5.03) to predict critical illness in hypotensive persons.

Conclusion

Median WBC counts, albumin values, and ATLAS scores differed in patients separated by CDI severity. A notable variance in albumin values and ATLAS scores between fluid responsive fulminant disease and critical illness was moreover seen. The finding suggests hypoalbuminemia and high ATLAS scores in hypotensive CDI patients may herald shock, ileus, or megacolon.

Hospital acquired Clostridioides difficile infection and risk factors for severity in a university hospital: A prospective study

BACKGROUND

Clostridioides difficile infection (CDI) is a well-known cause of health care-associated diarrhea. Data about CDI epidemiology of Turkey is limited. This study investigates CDI incidence, clinical characteristics, and factors associated with severe CDI in a tertiary care center university hospital.

METHODS

This is a case control study was conducted between 2012 and 2016. We included all patients, 18 years of age or more, with CDI diagnosis. For each patient diagnosed with CDI, information was collected concerning the severity of disease, treatment regimen, treatment response, disease recurrence, 30-day case fatality. Cases defined as severe hospital acquired CDI (HA-CDI) and controls defined as non-severe CDI patients.

RESULTS

We identified 100 cases of HA-CDI out of 111 patients. Total CDI incidence was 1.19/10,000 patient-days. The incidence decreased 32.5% during the study period. We identified severe CDI in 24% of patients. Age and admission to intensive care unit were independent risk factors for severe CDI.

CONCLUSION

This study reports a 5-year prospective epidemiology of CDI in a tertiary care center in Istanbul, Turkey. The findings of this study suggest that HA-CDI incidence and proportion of severe CDI is low compared to European and US literature. We believe that CDI is underreported, neglected but still an important health care associated infection in Turkey.

Advanced age and increased CRP concentration are independent risk factors associated with Clostridioides difficile infection mortality

Clostridioides difficile (C.difficile) is a Gram-positive, spore-forming, toxin-producing anaerobic bacillus, which is one of the most common causes of health-care-associated infection developed mainly by elderly patients. The objective of this study was to assess mortality among the patients of the Hospital for Infectious Diseases in Warsaw related to C.difficile infection. Analysis was conducted of 1638 records reporting the medical histories of patients hospitalized for the first time due to Clostridioides difficile infection (CDI) in the Hospital for Infectious Diseases in Warsaw from 2010 to 2017. The inclusion criteria were any (principal or secondary) discharge diagnosis code for CDI according to ICD-10 and being an adult (≥ 18 years). 108 out of 1638 (7%) of the patients died. The median age in this group was 83 years. The largest number of deaths (90%) occurred in the group of patients aged 65 years or older and 81–90 years old (53% of all the deaths). In the multivariate logistic regression model relevant only to the age groups, not to sepsis—age over 80 and over 90 were independent predictors of death, increasing the risk of death by 3.4 and 1.8 times, respectively. The result of the receiver operating curve (ROC) analysis determined the age of 77 years as the threshold value, indicating the increased risk of death (AUC 0.727, standard error 0.025, 95% CI 0.678–0.776, p < 0.0001). In addition, other quantitative variables, namely CRP, creatinine and leucocytes were studied and turned out to be independent death predictors as well. The diagnosis of sepsis increased the risk of death fourfold (OR = 4.042; 95% Cl 2.4–6.7; p < 0.001). Increased inflammatory parameters, namely CRP and white blood cell count, advanced age, particularly over the age of 80, as well as a diagnosis of sepsis are independent risk factors for death and could be used as predictive markers of poor outcome in CDI.

Risk Factors for Reoperation in Patients Hospitalized for Odontogenic Infections

PURPOSE

One of the most common adverse events after treatment of severe odontogenic infections is the need for a second procedure. The identification of risk factors for reoperation could help surgeons predict the need for reoperation or even tailor treatment to avoid this complication altogether. The purpose of this study was to identify risk factors associated with reoperation in patients hospitalized with odontogenic infections.

PATIENTS AND METHODS

We designed a retrospective cohort study from an eligible population of all patients treated at our institution for an odontogenic infection with incision and drainage under general anesthesia from August 1, 2015, to June 30, 2019. The primary outcome variable was a return to the operating room because of treatment failure. The potential predictor variables included demographic characteristics, history or physical examination findings from admission, admission laboratory values, initial computed tomography results, and medications provided during treatment. Statistical analysis was performed using the χ² test and logistic regression, and from these results, a multiple logistic regression model was created.

RESULTS

A total of 223 patients were included in the study. Men comprised 50.7% of the study population, and the average age was 38.9 ± 13.3 years. The mean number of involved spaces was 2.6 ± 1.7 spaces. Reoperation was performed in 25 patients (11.2%). In the adjusted model, an increased number of involved spaces (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 2.7) and increased age (OR, 1.05; 95% CI, 1.004 to 1.09) were associated with increased odds of reoperation, and antibiotic therapy with a penicillin-type antibiotic (OR, 0.1; 95% CI, 0.04 to 0.5) and dexamethasone use (OR, 0.9; 95% CI, 0.8 to 0.98) were negatively associated with reoperation.

CONCLUSIONS

Further studies could be directed at determining whether certain timing or dosing regimens of dexamethasone could be helpful in reducing adverse outcomes in patients with odontogenic infections or determining feasible strategies when penicillin allergies are reported.

Lactobacillus sp as a Probiotic for the Prevention of Clostridium difficile Associated Diarrhea

Background: Antibiotic treatment can disturb the resistance of the gastrointestinal flora to colonization. This may result in complications, the most serious of which is Clostridium difficile associated diarrhea (CDAD). The aim of this study was to determine the effectiveness of probiotics for the prevention of CDAD.Method: The databases used were Scopus, Proquest, CINAHL, Medline, Pubmed and ScienceDirect, limited to having been published in the last 5 years. A literature review followed the keyword search. The keywords used were probiotics, Clostridium difficile, associated, diarrhea, randomized, control and trial using "AND" and “OR”. Twelve trials with 5102 participants were included. Eight trials reported a preventive effect for CDAD using a mixture of 2 strains of lactobacillus, a mixture of 4 combination strains, a mixture of lactobacillus and Saccharomyces or a mixture of Bifidobacterium, Lactobacillus and Saccharomyces.Result: Our findings indicate that probiotics may prevent CDAD. Most probiotics contain a singular strain. The combination with lactobacillus sp was the most effective at preventing CDAD.Conclusion: In addition, 6 out of 8 trials had an in relation to preventing CDAD containing lactobacillus sp. Four studies said that there were some factors that meant that the probiotic could not reduce or prevent the CDAD.

Clostridium difficile infection in hospitalized octogenarian patients

AIM

To evaluate the risk factors and outcome of Clostridium difficile infection in hospitalized octogenarian patients.

METHODS

A retrospective analysis of risk factors and outcome of C. difficile infection in hospitalized octogenarians was carried out at two academic centers in Romania from January 2014 to September 2016. Demographic, clinical and laboratory characteristics; antibiotics and proton pump inhibitors use in-hospital and 2 months before admission; comorbidities; length of hospital stay; treatment; and outcome were carefully collected from the patients' medical charts and compared with those from octogenarians hospitalized during the same period.

RESULTS

A total of 286 octogenarians were hospitalized during the study period and among them 79 (27.6%) were diagnosed with C. difficile infection. On multivariate logistic regression analyses, the previous 2 months' hospitalizations (OR 10.231, 95% CI 1.769-58.965, P = 0.009), antibiotic use 2 months before admission (OR 12.596, 95% CI 1.024-15.494, P = 0.048), antibiotic treatment during hospitalization (OR 6.302, 95% CI 3.510-11.316, P < 0.0001), arterial hypertension (OR 11.228, 95% CI 1.917-65.783, P = 0.007), chronic kidney disease (OR 4.474, 95% CI 1.037-19.299, P = 0.045) and chronic cardiac failure (OR 7.328, 95% CI 2.068-25.967, P = 0.002) were independently associated with infection. Patients with infection had longer length of hospital stay than those without (15.3 ± 5.1 vs 11.1 ± 4.3 days, P < 0.0001). None of the patients with infection had severe disease, none required surgery and none died during hospitalization.

CONCLUSIONS

Hospitalized octogenarians with comorbidities, recently hospitalized or receiving antibiotic treatment are at risk for C. difficile infection. Clinicians evaluating such patients should have a high index of suspicion for this infection. Geriatr Gerontol Int 2018; 18: 315-320.