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Severity, outcomes of C. difficile infection improved in US urban area
Clostridium difficile infection showed less disease severity, better outcomes and lower mortality in an urban US population in 2009-2011 compared with the preceding 2-year period, according to recent study data.
Paul Feuerstadt MD, FACG, Medical Research Center of Connecticut, Gastroenterology Center of Connecticut, and colleagues performed a retrospective cohort study of 3,096 patients who had confirmed C. difficile infection (CDI) with diarrhea within 1 week after admission to Montefiore Medical Center in New York in 2-year periods between 2006 and 2011. Patients were grouped by time frame at diagnosis: CDI 06-08 (n=1,189), and CDI 09-11 (n=1,907). CDI 09-11 patients were older (P=.01), less frequently Caucasian (P<.001) and had higher comorbidity (P=.02).
Antibiotic exposure
Exposure to quinolones (P<.001), oral vancomycin (P<.001) and oral metronidazole (P<.01) 3 months before diagnosis was reduced in the CDI 09-11 group, while exposure to macrolide was increased (P<.001). In the severe CDI 09-11 subgroup (n=382), exposure to macrolide (P<.001) and penicillin (P<.05) was increased while exposure to quinolone (P<.05) and oral vancomycin (P<.05) was decreased compared with the severe CDI 06-08 subgroup (n=243).
Paul Feuerstadt
Disease evaluation
White blood cell count (WBC) was lower at diagnosis and peak (both P<.001) in the CDI 09-11 group, and creatinine was higher at diagnosis (P=.002). CT scan and colonoscopy were performed less frequently in the CDI 09-11 group (both P<.01), however, colonoscopic pseudeomembrane detection was more likely in this group (P<.001). In the severe CDI 09-11 subgroup, WBC at diagnosis (P<.001) and at peak (P<.01) were lower, but CT scans were more frequent (P<.05).
Treatment patterns
Patients in the CDI 09-11 group received oral metronidazole for shorter periods (P<.001), IV metronidazole for longer periods (P=.04), and vancomycin monotherapy more frequently (P<.001). They also were switched from metronidazole to vancomycin more frequently (P<.001), and were overall less frequently exposed to any metronidazole (P<.001). Similar differences were seen in the severe subgroups, with severe CDI 09-11 less frequently receiving any oral metronidazole (P<.001) and for shorter time periods (P<.05), oral metronidazole monotherapy for shorter time periods (P<.01), more frequent oral vancomycin monotherapy (P<.01) and more frequent switching from vancomycin to metronidazole (P<.01).
Outcomes
Patients in the CDI 09-11 group were discharged on treatment more often compared with the CDI 06-08 group (71.2% vs. 64%; P<.001). Mortality rates in the CDI 09-11 group were lower at 30 days (13.1% vs. 17.1%; P<.01) and 6 months (34.8% vs. 38.4%; P=.04). In subgroup analysis, patients aged 70 to 79 years and 80 to 89 years had decreased mortality rates (13.3% vs. 22%; P<.01, and 18.1% vs. 29.2%; P<.001, respectively). The severe CDI 09-11 subgroup had lower 30-day mortality (23.3% vs. 31.3%; P<.05), and lower mortality in patients aged 70 to 79 years (24.3% vs. 39.5%; P=.03), 80-89 (25.5% vs. 46.4%) and 90-99 (34.1% vs. 64.7%; P=.03).
“Our study shows that the epidemiology of CDI in a United States urban environment is changing,” Feuerstadt told Healio.com/Gastroenterology. “Despite our more modern cohort being older with more medical comorbidities, this group had less severe disease, more aggressive management with decreased mortality compared with 2006-2008. Clinicians appear to be more appropriate with their workup and therapy for CDI resulting in better outcomes and this pattern should continue as we face increasing incidence of this disease.”
Disclosure: Lawrence J. Brandt, MD, is on the scientific advisory committee for Cipac, and Paul Feuerstadt, MD, is on the speaker’s bureau for Cubist Pharmaceuticals.