Brief Article
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World J Gastroenterol. Nov 28, 2013; 19(44): 8034-8041
Published online Nov 28, 2013. doi: 10.3748/wjg.v19.i44.8034
Predictors of Clostridium difficile infection severity in patients hospitalised in medical intensive care
Nagham Khanafer, Abdoulaye Touré, Cécile Chambrier, Martin Cour, Marie-Elisabeth Reverdy, Laurent Argaud, Philippe Vanhems
Nagham Khanafer, Philippe Vanhems, Laboratory of Epidemiology and Public Health, CNRS UMR 5558, University of Lyon, 69 373 Lyon, France
Nagham Khanafer, Abdoulaye Touré, Philippe Vanhems, Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils of Lyon, 69437 Lyon, France
Cécile Chambrier, INSERM Unit 1060, INRA 1235, University of Lyon, 69921 Oullins, France
Abdoulaye Touré, Cécile Chambrier, Clinical Nutrition Intensive Care Unit, Croix Rousse Hospital, Hospices Civils of Lyon, 69317 Lyon, France
Martin Cour, Laurent Argaud, Medical Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils of Lyon, 69437 Lyon, France
Marie-Elisabeth Reverdy, Microbiology Laboratory, Hospices Civils of Lyon, 69677 Bron, France
Author contributions: Khanafer N contributed to the conception, data acquisition, analysis and interpretation, drafting of manuscript and final approval; Touré A actively participated in the conception, data acquisition, analysis and interpretation, revising and final approval of the manuscript; Chambrier C, Argaud L and Cour M partook in the interpretation, revising and final approval of the manuscript; Reverdy ME performed the microbiological tests; Vanhems P was involved in the conception, interpretation, revising and final approval of the manuscript.
Supported by A grant for her PhD from Sanofi Pasteur, France, to Khanafer N
Correspondence to: Nagham Khanafer, PharmD, MPH, PhD, Epidemiology and Infection Control Unit, Edouard Herriot Hospital, Hospices Civils of Lyon, 69437 Lyon, Cedex 03, France. nagham.khanafer@chu-lyon.fr
Telephone: +33-4-27858063 Fax: +33-4-72110726
Received: April 30, 2013
Revised: July 21, 2013
Accepted: July 9, 2013
Published online: November 28, 2013
Processing time: 224 Days and 18.6 Hours
Abstract

AIM: To describe and analyse factors associated with Clostridium difficile infection (CDI) severity in hospitalised medical intensive care unit patients.

METHODS: We performed a retrospective cohort study of 40 patients with CDI in a medical intensive care unit (MICU) at a French university hospital. We include patients hospitalised between January 1, 2007 and December 31, 2011. Data on demographics characteristics, past medical history, CDI description was collected. Exposure to risk factors associated with CDI within 8 wk before CDI was recorded, including previous hospitalisation, nursing home residency, antibiotics, antisecretory drugs, and surgical procedures.

RESULTS: All included cases had their first episode of CDI. The mean incidence rate was 12.94 cases/1000 admitted patients, and 14.93, 8.52, 13.24, 19.70, and 8.31 respectively per 1000 admitted patients annually from 2007 to 2011. Median age was 62.9 [interquartile range (IQR) 55.4-72.40] years, and 13 (32.5%) were women. Median length of MICU stay was 14.0 d (IQR 5.0-22.8). In addition to diarrhoea, the clinical symptoms of CDI were fever (> 38 °C) in 23 patients, abdominal pain in 15 patients, and ileus in 1 patient. The duration of diarrhoea was 13.0 (8.0-19.5) d. In addition to diarrhoea, the clinical symptoms of CDI were fever (> 38 °C) in 23 patients, abdominal pain in 15 patients, and ileus in 1 patient. Prior to CDI, 38 patients (95.0%) were exposed to antibiotics, and 12 (30%) received at least 4 antibiotics. Fluoroquinolones, 3rd generation cephalosporins, coamoxiclav and tazocillin were prescribed most frequently (65%, 55%, 40% and 37.5%, respectively). The majority of cases were hospital-acquired (n = 36, 90%), with 5 cases (13.9%) being MICU-acquired. Fifteen patients had severe CDI. The crude mortality rate within 30 d after diagnosis was 40% (n = 16), with 9 deaths (9 over 16; 56.3%) related to CDI. Of our 40 patients, 15 (37.5%) had severe CDI. Multivariate logistic regression showed that male gender [odds ratio (OR): 8.45; 95%CI: 1.06-67.16, P = 0.044], rising serum C-reactive protein levels (OR = 1.11; 95%CI: 1.02-1.21, P = 0.021), and previous exposure to fluoroquinolones (OR = 9.29; 95%CI: 1.16-74.284, P = 0.036) were independently associated with severe CDI.

CONCLUSION: We report predictors of severe CDI not dependent on time of assessment. Such factors could help in the development of a quantitative score in ICU’s patients.

Keywords: Clostridium difficile, Health-care associated infection, Hospital-acquired infection, Intensive care unit, Nosocomial infection, Severe Clostridium difficile infection

Core tip: We reported that male gender, rising serum C-reactive protein level, and previous exposure to fluoroquinolones were independently associated with severe Clostridium difficile infection (CDI) in medical intensive care unit. This could help in the development of a quantitative severity score that could fuel comparative effectiveness studies and prospective trials of CDI therapy in critically-ill patients.