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Fulminant Clostridium difficile colitis: Patterns of care and predictors of mortality

Elizabeth Sailhammer, MD, Katherine Carson, BS,, Yuchiao Chang, PhD, Nikolaos Zacharias, MD, Marc A. DeMoya, MD, George C. Velmahos, MD;
Massachusetts General Hospital- Department of Surgery, Division of Trauma , Boston, MA


PURPOSE OF STUDY
To identify predictors of mortality and the need for colectomy among patients with fulminant Clostridium difficile colitis (FCDC).

METHODS USED:
We reviewed the records of 4,796 inpatients with a diagnosis of CDC from January 1996 to December 2007, and identified 199 (4.1%) with FCDC, as defined by the need for colectomy or admission to the ICU for CDC. Our primary outcome was risk of inpatient mortality according to clinical predictors, colectomy, and medical team, by multivariate analysis.

SUMMARY OF RESULTS:
In-hospital mortality for FCDC was 34.7%. Independent predictors of mortality included: 1) age ?70 years, 2) severe leukocytosis or leukopenia (?35,000 or <4,000 cells/mm3) or bandemia (bands ?10%), and 3) cardiorespiratory failure (intubation or vasopressors). When all three factors were present, mortality was 57.1%; when all three were absent, it was 0%. Patients who underwent colectomy had a trend towards decreased mortality (OR: 0.49 [0.21-1.1], p=0.085). Among patients admitted primarily for FCDC, care on the surgical service compared to the non-surgical services resulted in a higher rate of operation (85.1% vs 11.2%, p<0.0001) and lower mortality (12.8% vs 39.3%, p=0.001). Patients admitted directly to surgery had a shorter interval from admission to operation (0 vs. 1.72.8 days, p = 0.001).

CONCLUSIONS:
Despite awareness and treatment, FCDC remains a highly lethal disease. Reliable predictors of mortality exist and should be used to prompt aggressive surgical intervention. Survival is higher in the surgical than the non-surgical services, possibly because of more frequent and earlier operations.

TABLES AND CHARTS:
Table: Independent predictors of mortality in FCDC (n=199)
Factor Mortality, n (%) OR [95%CI] p-value
Age > 70 years
< 70 years
47 (40.2%)
22 (26.8%)
2.2 [1.0 4.8] 0.04
WBC > 35 or < 4 K/mm3
< 35 and > 4 K/mm3
38 (46.3%)
31 (26.5%)
4.2 [1.9 9.1] 0.0003
Bands > 10%
< 10%
53 (40.5%)
16 (23.5%)
2.8 [1.3 6.5] 0.01
Vasopressors Yes
No
48 (52.2%)
21 (19.6%)
4.0 [1.9 8.5] 0.0004
Intubation Yes
No
45 (52.9%)
24 (21.1%)
4.7 [2.1 10.5] 0.0001
Oral vancomycin Yes
No
19 (21.6%)
50 (45.0%)
0.25 [0.11 0.55] 0.0006
Colectomy Yes
No
24 (32.0%)
45 (36.3%)
0.49 [0.21 1.1] 0.085

 

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