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Analysis of 30-Day Mortality for Clostridium difficile-Associated Disease in the ICU Setting^*

^* From the Department of Pulmonary and Critical Care Medicine (Drs. Kenneally and Kollef), Washington University School of Medicine; Department of Pharmacy (Drs. Rosini, Skrupky, Hollands, Martinez, McKenzie, Murphy, Smith, and Micek), Barnes-Jewish Hospital; and Medical Informatics (Mr. Doherty), BJC Healthcare, St. Louis, MO.

Correspondence to: Marin H. Kollef, MD, FCCP, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8052, St. Louis, MO 63110; e-mail: mkollef{at}im.wustl.edu

Abstract

Objective: To examine the 30-day mortality rate among patients with Clostridium difficile-associated disease (CDAD) requiring intensive care.

Design: A retrospective, single-center, observational, cohort study.

Setting: Barnes-Jewish Hospital, a 1,200-bed, urban, teaching facility.

Patients: Adult patients admitted to the ICU identified to have CDAD by enzyme immunoassay.

Interventions: Retrospective data collection from automated hospital, microbiology, and pharmacy databases.

Measurements and main results: Two hundred seventy-eight patients with CDAD admitted to an ICU were identified over a 2-year period. Two hundred six patients (74.1%) received prior antibiotic therapy. The overall 30-day mortality rate was 36.7% (n = 102). Logistic regression analysis identified septic shock (adjusted odds ratio, 1.96; 95% confidence interval [CI], 1.47 to 2.61; p = 0.018), ward-to-ICU transfer (adjusted odds ratio, 2.12; 95% CI, 1.62 to 2.79; p = 0.006), and increasing APACHE (acute physiology and chronic health evaluation) II scores (1-point increments) [adjusted odds ratio, 1.09; 95% CI, 1.07 to 1.12; p < 0.001] as independent predictors for 30-day mortality. The attributable mortality associated with CDAD was estimated to be 6.1% (95% CI, – 1.7 to 13.9%; p = 0.127). CDAD was associated with an excess ICU length of stay (2.2 days) and hospital length of stay (4.5 days).

Conclusions: We found a high 30-day crude mortality among patients with CDAD in the ICU setting. Although the attributable mortality from CDAD was relatively low, excess length of stay in the ICU and hospital was observed with CDAD. ICUs should routinely employ infection control efforts aimed at minimizing the occurrence of CDAD because of the excess morbidity associated with this nosocomial infection.

Key Words: antibiotics • Clostridium difficile • intensive care • outcome