Fulminant Colitis in Hospital-Onset Clostridium difficile Infection (CDI): Incidence, Trend, and Risk Factors

Abstract

Background. The epidemiology of hospital-onset CDI (HOCDI) has changed with increased overall incidence highlighted by outbreaks of disease more severe than previously observed. The data of incidence, trend and risk factors for fulminant Clostridium difficile colitis (FCDC) in HOCDI are scarce. Methods. Using Nationwide Inpatient Sample (NIS, 2005-2012), we identified adult patients (>18 years old) with CDI by ICD-9-CM codes. Those with secondary diagnosis of CDI and over 2 days of hospitalization were considered as HOCDI. We defined FCDC as HOCDI with subsequent development of megacolon, bowel perforation and/or need for colectomy. HOCDI subjects were divided into non-FCDC and FCDC groups. The incidence trends of HOCDI and FCDC were analyzed. The risk factors studied by logistic regression included demographics, hospital characteristics, underlying diseases and procedures which might increase CDI, and comorbidities associated with disease severity measure. Results. Totally 1,705,089 episodes of HOCDI were identified, including 29,984 with FCDC. The incidences of HOCDI in 2005-2010 were stable (0.61% ~ 0.65%) and then increased to 0.72% in 2011-2012. In the 8-year study period, the incidence of FCDC in HOCDI increased from 1.3% to 2% (figure). Mortality in the FCDC group (22.7%) was 2.3 times higher than in the non-FCDC group (10.0%). Comparing with nonteaching hospitals with small bed size, higher incidence of FCDC was found in teaching hospitals with large bed size (P < 0.001). The major risks for FCDC were the underlying bowel diseases including colon ischemia (odds ratio [OR] = 15.5), appendicitis (OR = 5.7), inflammatory bowel disease (OR = 5.0), bowel obstruction (OR = 4.7), diverticulitis/diverticulosis (OR = 2.5), and colon cancer (OR = 2.4). The Charlson index could not predict the development of FCDC. [Figure Presented].