Infection Control & Hospital Epidemiology (2019), 40,65–71 doi:10.1017/ice.2018.280
Original Article
Clostridium difficile infection increases acute and chronic morbidity and mortality
Margaret A. Olsen PhD1,2, Dustin Stwalley MS1, Clarisse Demont PhD3 and Erik R. Dubberke MD1 1Department of Medicine, Washington University School of Medicine, St Louis, Missouri, 2Department of Surgery, Washington University School of Medicine, St Louis, Missouri and 3Sanofi Pasteur, Lyon, France
Abstract
Objective: In this study, we aimed to quantify short- and long-term outcomes of Clostridium difficile infection (CDI) in the elderly, including all-cause mortality, transfer to a facility, and hospitalizations. Design: Retrospective study using 2011 Medicare claims data, including all elderly persons coded for CDI and a sample of uninfected persons. Analysis of propensity score-matched pairs and the entire population stratified by the propensity score was used to determine the risk of all-cause mortality, new transfer to a long-term care facility (LTCF), and short-term skilled nursing facility (SNF), and subsequent hospitalizations within 30, 90, and 365 days. Results: The claims records of 174,903 patients coded for CDI were compared with those of 1,318,538 control patients. CDI was associated with increased risk of death (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.74–1.81; attributable mortality, 10.9%), new LTCF transfer (OR, 1.74; 95% CI, 1.67–1.82), and new SNF transfer (OR, 2.52; 95% CI, 2.46–2.58) within 30 days in matched-pairs analyses. In a stratified analysis, CDI was associated with greatest risk of 30-day all-cause mortality in persons with lowest baseline probability of CDI (hazard ratio [HR], 3.04; 95% CI, 2.83–3.26); the risk progressively decreased as the baseline probability of CDI increased. CDI was also associated with increased risk of subsequent 30-day, 90-day, and 1-year hospitalization. Conclusions: CDI was associated with increased risk of short- and long-term adverse outcomes, including transfer to short- and long-term care facilities, hospitalization, and all-cause mortality. The magnitude of mortality risk varied depending on baseline probability of CDI, suggesting that even lower-risk patients may benefit from interventions to prevent CDI.
(Received 15 June 2018; accepted 30 August 2018; electronically published 9 November 2018)
Clostridium difficile is the most common microorganism asso- ciated with death in persons with gastroenteritis1,2 and the single most common organism responsible for US healthcare-associated infections.3 Although C. difficile infection (CDI) is clearly asso- ciated with morbidity and mortality, the incremental impact of CDI on mortality is not clear. In a 2015 review of CDI outcomes, all-cause mortality ranged from 11.8% to 38%, and attributable mortality ranged from 0% to 16.7%, depending on the time frame to assess mortality, statistical methods, and whether the investi- gations were conducted during endemic or epidemic periods of CDI.4 A prior review of European studies found similar hetero- geneity in all-cause hospital mortality (4%–37%) and CDI- attributable mortality (0%–23%).5 Variation in all-cause and attributable CDI mortality is also likely due to differences in patient populations. Because CDI
Authors for correspondence: Margaret A. Olsen, PhD, MPH, Division of Infectious
Diseases, Campus Box 8051, Washington University School of Medicine, 4523 Clayton Ave, St Louis, MO 63110. E-mail:
molsen@wustl.edu or Erik R. Dubberke, MD, MSPH, Division of Infectious Diseases, Campus Box 8051, Washington University School of Medicine, 4523 Clayton Ave, St Louis, MO 63110. E-mail:
edubberk@wustl.edu PREVIOUS PRESENTATION: The preliminary findings of this study were presented
at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) conference on April 10, 2016 in Amsterdam, Netherlands.
Cite this article: Olsen MA, et al. (2019). Clostridium difficile infection increases acute
and chronic morbidity and mortality. Infection Control & Hospital Epidemiology 2019, 40, 65–71. doi: 10.1017/ice.2018.280
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
incidence and risk of complicated infection are much higher in the elderly than in younger persons,2,6,7 focus on outcomes in the elderly is important. Recently, 2 studies reported CDI mortality in the elderly using Medicare data. Drozd et al8 found 1.9% 30-day attributable mortality after hospital-onset CDI, although their analysis included younger beneficiaries (ie, end-stage renal dis- ease, disabled). Shorr et al9 reported attributable CDI mortality of 14.9% at 60 days and 19.2% at 1 year in the elderly. Prior studies estimating the risk of mortality due to CDI have not considered the possibility of effect modification, in which the risk is not uniform but varies depending on other factors.10 The data on CDI-attributable morbidity are even more limited
than data for mortality. Adults with CDI in a managed care plan were at higher risk of subsequent hospitalization, intensive care unit stay, and emergency department utilization than enrollees without CDI, particularly if they had recurrent CDI.11 Patients with CDI have been shown to be at increased risk of short- and longer-term hospital readmission,8,12–14 and discharge to a nur- sing care facility after hospitalization.15 We used Medicare data to better understand the impact of
CDI on all-cause mortality, short-term morbidity, and long-term morbidity in the elderly. We performed 2 different analyses to estimate differential risk of outcomes in CDI compared to uninfected persons, pooled across all persons and within strata of CDI risk. We used this approach to determine whether
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