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168 Relationship of CDC Surveillance Definitions and Mortality due to Clostridium difficile Infection (CDI) in Older Adults in South Eastern Michigan-A Multicenter Study

Saturday, April 2, 2011
Trinity Ballroom (Hilton Anatole)
Teena Chopra, MD , Detroit Medical Center, Wayne State University, Detroit, MI
Gagandeep Cheema, BS , Wayne State University, Detroit, MI
Nena Auraha, BS , Wayne State University, Detroit, MI
Jose F. Echaiz, MD , Henry Ford Hospital, Detroit, MI
Laura Johnson , Henry Ford Hospital, Detroit, MI
Richard Severson, PhD , Wayne State University, Detroit, MI
Rama Thyagarajan, MD , Oakwood Health Care System, Dearborn, MI
Keith Mullins, BS , Wayne State University, Detroit, MI
Dror Marchaim, MD , Detroit Medical Center, Wayne State University, Detroit, MI
Suchitha Bheemreddy, MD , Detroit Medical Center, Wayne State University, Detroit, MI
Ahmad Mohammadieh , Detroit Medical Center,Wayne State University, Detroit, MI
Christopher Saddler, BS , Wayne State University, Detroit, MI
Sorabh Dhar, MD , Detroit Medical Center, Wayne State University, Detroit, MI
Keith .S Kaye, MD, MPH , Detroit Medical Center, Wayne State University, Detroit, MI
George Alangaden, MD , Detroit Medical Center,Wayne State University, Detroit, MI
Background: Limited data exists regarding the epidemiology of community-onset CDI in older adults.

Objective: The goals of this study were to investigate the risk factors and outcomes of community-onset CDI in the older adults.

Methods: The epidemiology and outcomes of community-onset CDI were evaluated in elderly patients aged >60 years hospitalized at 5 acute-care hospitals in south-east Michigan between January 2005 and December 2008. CDI was defined as a patient with diarrhea and a positive stool C. Diff toxin enzyme immunoassay. CDI was classified using the CDC surveillance definitions: a) Hospital-onset CDI  (HO-CDI), CDI onset ≥48 hrs after hospitalization; b) Community-onset CDI (CO-CDI), CDI onset < 48 hours after hospital admission; c) CO-healthcare-facility associated CDI (CO-HCFA), CDI that occurred < 4 weeks after discharge from a HCF; d) CO-community associated CDI (CO-CA), CDI onset >12 weeks after discharge from a HCF; e) CO-indeterminate CDI (CO-CI), CDI that did not fit any of the above criteria for an exposure setting. Variables within the study included demographics, laboratory findings, co-morbidities, and death due to CDI within 30 days.

Results: The cohort comprised 428 older adults with CDI. 153 CO-CDI cases were compared to 275 HO-CDI. Mean age for the two groups were 77 vs 76 years (p=0.09). Females were more likely to develop CO-CDI as compared to HO-CDI (65% vs 58%,p=0.2). History of prior CDI was independently associated with greater risk of CO-CDI (OR=2.5, CI 1.1-5.5). Although the median McCabe score at admission favored CO-CDI, 2 [IQR-3-2] vs 1 [IQR-1-1] for HO-CDI (p=0.3), mortality due to CDI in CO-CDI was higher 27 (18%) versus HO-CDI 34 (12%) (p=0.15).

Classification of CDI

Mean Age±SD

Death due to CDI

HO-HCFA

76±9.9

12.4%

CO-HCFA

75±8.6

6.7%

CO-CA

79.4±9.9

28.4%

CO-CI

75±7.8

10.7%

Conclusions: In our cohort of older adults, a prior episode of CDI was associated with 2.5 times higher risk of CO-CDI. Overall mortality due to CDI was higher in patients with CO-CDI, and greatest in patients with CO-CA CDI. The reasons for adverse outcomes seen in patients with CO-CA are unclear at this point but may be related to older age, lack of early recognition of CDI, or a more virulent community strain of C. difficile. Close monitoring and aggressive clinical management should be considered in patients with CO-CA CDI.