Kimberly A. Reske

Clostridium difficile—Associated Disease in a Setting of Endemicity: Identification of Novel Risk Factors

BACKGROUND Previous studies of risk factors for Clostridium difficile-associated disease (CDAD) have been limited by small sample sizes and case-control study designs. Many of these studies were performed during outbreaks of CDAD. Colonization pressure and use of fluoroquinolones, vancomycin, and gastric acid suppressors have not been fully evaluated as risk factors for CDAD. The purpose of this study was to determine risk factors for endemic CDAD, including CDAD pressure, a modified version of colonization pressure. METHODS We performed a retrospective cohort study of 36,086 patients admitted to Barnes-Jewish Hospital (St. Louis, MO) during the period from 1 January 2003 through 31 December 2003. Administrative, laboratory, and pharmacy data were collected from electronic hospital databases. Colonization pressure was measured through a surrogate variable (i.e., CDAD pressure). Multivariable pooled logistic regression models were used to evaluate independent risk factors for CDAD. RESULTS The analysis included 382 CDAD case patient admissions and 35,704 non-case patient admissions. Significant independent risk factors for CDAD included increasing age, admission(s) in the previous 60 days, hypoalbuminemia, leukemia and/or lymphoma, mechanical ventilation, and receipt of antimotility drugs, histamine-2 blockers, proton pump inhibitors, intravenous vancomycin, fluoroquinolones, and first-, third-, or fourth-generation cephalosporins. Increasing CDAD pressure was a strong risk factor for CDAD (for a CDAD pressure >1.4, the odds ratio was 4.0; 95% confidence interval, 2.9-5.6). Receipt of metronidazole was protective against CDAD (odds ratio, 0.5; 95% confidence interval, 0.3-0.6). CONCLUSIONS This study identified the previously underrecognized CDAD risk factors of CDAD pressure and vancomycin. More studies are needed to evaluate the relationship between CDAD, these risk factors, and use of gastric acid suppressors and fluoroquinolones.

Short- and Long-Term Attributable Costs of Clostridium difficile-Associated Disease in Nonsurgical Inpatients

BACKGROUND The incidence of Clostridium difficile-associated disease (CDAD) is increasing. There are few data on the short-term and long-term attributable costs of CDAD. The objective of this study was to determine the acute and 180-day attributable inpatient costs of CDAD. METHODS We performed a retrospective cohort study of all patients without operating room costs who were admitted for > or =48 h to Barnes-Jewish Hospital, a tertiary care hospital in St. Louis, Missouri, 1 January 2003-31 December 2003 (n = 24,691). Attributable costs of CDAD were determined by multivariable linear regression and propensity-score matched-pairs analyses (n = 684) for the hospitalization in which CDAD occurred and per patient over a 180-day period, including the initial hospitalization. RESULTS CDAD was associated with

ICD-9 codes and surveillance for Clostridium difficile-associated disease.

2454 (95% confidence interval,

Attributable outcomes of endemic Clostridium difficile-associated disease in nonsurgical patients.

2380-

Epidemiological Model for Clostridium difficile Transmission in Healthcare Settings

2950; increase in cost, 41%) attributable costs per CDAD episode by linear regression and with

Recurrent Clostridium difficile infection is associated with increased mortality

3240 attributable costs (P < .001; increase in cost, 33%) by propensity-score matched-pairs analysis. CDAD was associated with

The Impact of ICD-9-CM Code Rank Order on the Estimated Prevalence of Clostridium difficile Infections

5042 (95% confidence interval,

Severity of Clostridium difficile-associated disease (CDAD) in allogeneic stem cell transplant recipients: Evaluation of a CDAD severity grading system

3797-

Development and validation of a recurrent Clostridium difficile risk-prediction model.

6481; increase in cost, 53%) attributable inpatient costs over 180 days by linear regression and with

Attributable Inpatient Costs of Recurrent Clostridium difficile Infections

7179 attributable costs for inpatient care (P < .001; 48% increase in costs) by propensity-score matched-pairs analysis. CONCLUSIONS CDAD was associated with a significant increase in costs for inpatient care and increased costs at 180 days after the initial hospitalization when the CDAD episode occurred.