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Outcome of ICU patients with Clostridium difficile infection

Jean-Ralph Zahar12, Carole Schwebel5, Christophe Adrie3, Maité Garrouste-Orgeas14, Adrien Français1, Aurélien Vesin1, Molière Nguile-Makao1, Alexis Tabah15, Kevin Laupland16, Alban Le-Monnier78, Jean-François Timsit135* and the OUTCOMEREA study group

Author Affiliations

1 INSERM U823; University Grenoble 1 - Albert Bonniot Institute, Rond-point de la Chantourne, Grenoble, 38042, France

2 Microbiology and Infection Control Unit, Necker Teaching Hospital, 145 rue de sèvres, Paris 75015, France

3 Medical-Surgical ICU, Delafontaine Hospital, 2 rue du docteur Delafontaine, Saint-Denis, 93205, France

4 ICU, Saint Joseph Hospital, 185 Rue Raymond Losserand, Paris, 75014, France

5 Medical ICU, Albert Michallon Teaching Hospital, Boulevard de la Chantourne, Grenoble, 38043, France

6 Critical Care Medicine, Peter Lougheed Centre and University of Calgary, 26th Street NE, Calgary, AB T1Y 6J4, Canada

7 Microbiology department, André Mignot Hospital, 177 rue de Versailles, Le Chesnay, 78157, France

8 EA 4043, USC INRA, Paris-Sud 11 University, 5 Rue Jean Baptiste Clément, Châtenay Malabry, 92290, France

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Critical Care 2012, 16:R215  doi:10.1186/cc11852


See related letter by Nagella et al., http://ccforum.com/content/17/1/415

Published: 5 November 2012

Abstract

Introduction

As data from Clostridium difficile infection (CDI) in intensive care unit (ICU) are still scarce, our objectives were to assess the morbidity and mortality of ICU-acquired CDI.

Methods

We compared patients with ICU-acquired CDI (watery or unformed stools occurring ≥ 72 hours after ICU admission with a stool sample positive for C. difficile toxin A or B) with two groups of controls hospitalized at the same time in the same unit. The first control group comprised patients with ICU-acquired diarrhea occurring ≥ 72 hours after ICU admission with a stool sample negative for C. difficile and for toxin A or B. The second group comprised patients without any diarrhea.

Results

Among 5,260 patients, 512 patients developed one episode of diarrhea. Among them, 69 (13.5%) had a CDI; 10 (14.5%) of them were community-acquired, contrasting with 12 (17.4%) that were hospital-acquired and 47 (68%) that were ICU-acquired. A pseudomembranous colitis was associated in 24/47 (51%) ICU patients. The median delay between diagnosis and metronidazole administration was one day (25th Quartile; 75th Quartile (0; 2) days). The case-fatality rate for patients with ICU-acquired CDI was 10/47 (21.5%), as compared to 112/443 (25.3%) for patients with negative tests. Neither the crude mortality (cause specific hazard ratio; CSHR = 0.70, 95% confidence interval; CI 0.36 to 1.35, P = 0.3) nor the adjusted mortality to confounding variables (CSHR = 0.81, 95% CI 0.4 to 1.64, P = 0.6) were significantly different between CDI patients and diarrheic patients without CDI. Compared to the general ICU population, neither the crude mortality (SHR = 0.64, 95% CI 0.34 to 1.21, P = 0.17), nor the mortality adjusted to confounding variables (CSHR = 0.71, 95% confidence interval (CI) 0.38 to 1.35, P = 0.3), were significantly different between the two groups. The estimated increase in the duration of stay due to CDI was 8.0 days ± 9.3 days, (P = 0.4) in comparison to the diarrheic population, and 6.3 days ± 4.3 (P = 0.14) in comparison to the general ICU population.

Conclusions

If treated early, ICU-acquired CDI is not independently associated with an increased mortality and impacts marginally the ICU length of stay.