Sepsis/Infection
Is Clostridium difficile infection an increasingly common severe disease in adult intensive care units? A 10-year experience

https://doi.org/10.1016/j.jcrc.2015.02.011Get rights and content

Abstract

Purpose

Despite the high concentration of patients with known risk factors for Clostridium difficile infection (CDI) in intensive care units (ICUs), data on ICU patients are scarce. The aim of this study was describe the incidence, clinical characteristics, and evolution of CDI in critically ill patients.

Materials and methods

From 2003 to 2012, adult patients admitted to an ICU (A-ICU) and positive for CDI were included and classified as follows: pre-ICU, if the positive sample was obtained within ± 3 days of ICU admission; in-ICU, if obtained after 3 days of ICU admission and up to 3 days after ICU discharge.

Results

We recorded 4095 CDI episodes, of which 328 were A-ICU (8%). Episodes of A-ICU decreased from 19.4 to 8.7 per 10 000 ICU days of stay (P < .0001). Most A-ICU CDIs (66.3%) were mild to moderate. Pre-ICU episodes accounted for 16.2% and were more severe complicated than in-ICU episodes (11% vs 0%; P = .020). Overall mortality was 28.6%, and CDI-attributable mortality was only 3%.

Conclusion

The incidence of A-ICU CDI has decreased steadily over the last 10 years. A significant proportion of A-ICU CDI episodes are pre-ICU and are more severe than in-ICU CDI episodes. Most episodes of A-ICU CDI were nonsevere, with low associated mortality.

Introduction

Clostridium difficile infection (CDI) is a major cause of nosocomial and nonnosocomial diarrhea. During the last decade, CDI has become a cause for concern and a potential marker of deficiencies in antimicrobial stewardship in developed countries [1], [2], [3].

Morbidity, mortality, and cost of CDI episodes are an intolerable burden for the health system, and its control must be approached by multidisciplinary teams [4], [5], [6].

Robust data on the incidence of CDI in intensive care units (ICUs), the place of acquisition of the ICU episodes and the clinical consequences of CDI, are lacking, and most published articles only report cases acquired in the ICU [7], [8], [9], [10].

For the last 10 years, our institution has kept a prospective record of all episodes of CDI diagnosed in the hospital. This record enables us to assess incidence, incidence density, recurrences, length of ICU stay, length of hospital stay, and mortality of CDI in adult ICU (A-ICU) patients (A-ICU CDI). It also enables us to compare cases admitted to the ICU with CDI and cases of CDI acquired in the ICU.

Section snippets

Setting

Our institution is a large teaching hospital that provides care for a population of between 704 000 and 812 000 inhabitants. During the study period, the number of beds ranged from 1300 to 2500.

The institution has all the services of a general teaching hospital and treats a large population of immunocompromised patients.

The hospital has 4 A-ICUs: a medical ICU (M-ICU) with 22 beds, a surgical ICU (S-ICU) with 20 beds, a major heart surgery ICU (MHS-ICU) with 14 beds, and a coronary ICU (C-ICU)

Admissions to the hospital and to A-ICUs

During the study period, our institution had 582 042 admissions and 4 656 570 days of hospital stay. The number of admissions to A-ICUs during the study period was 37 409, with a total of 194 667 days of ICU stay. The distribution by ICU was as follows: M-ICU, 8817 admissions; S-ICU, 12 125 admissions; MHS-ICU, 6185 admissions; and C-ICU, 10 282 admissions.

Incidence and secular trends of CDI episodes in the hospital and in ICUs

Fig. 1 and Table 1 summarize the incidence of CDI episodes and secular trends both in ICU patients and in the remaining hospital populations.

During

Discussion

Overall, only 8% of all CDI episodes in our institution occurred in ICU patients. The incidence density of CDI has been decreasing steadily in our A-ICU during the last 10 years and has reached levels similar to those recorded in other hospital areas. A significant percentage of A-ICU CDI episodes (16%) are acquired before ICU admission and are more severe than in-ICU episodes. Despite the critical situation of ICU patients, most CDI episodes occurring in the ICU were nonsevere, and mortality

Potential conflicts of interest

The authors declare no conflicts of interest.

Role of funding source

This work was partially supported by Astellas Pharma, Inc; the Rafael del Pino Foundation; and the Fondo de Investigaciones Sanitarias, Research Project number PI13/00687. Elena Reigadas holds a grant from the Río Hortega program, Carlos III Health Institute, Spanish Government.

Acknowledgments

The authors thank Thomas O’Boyle for his help in the preparation of the manuscript and Cristina Fernández for the statistical analysis.

Some of the results of this study were previously presented at the “International Congress of Antimicrobial Agents and Chemotherapy” as a Poster (10th September, 2013; Denver, Colorado, United States).

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