Adherence to Guidelines for Treatment of Clostridium difficile Infection and Clinical Outcomes at a Tertiary Care University Hospital: A Retrospective Study

Background: Clostridium difficile infection (CDI) is a major burden to the US healthcare system. It is associated with increased hospital costs, length of hospital stay, and morbidity and mortality. Despite guidelines published by IDSA in 2010 stratifying treatment based on disease severity, management of CDI remains variable. This study aims to evaluate current guideline adherence of CDI treatment and clinical outcomes at a tertiary care university hospital.

Methods: This is a retrospective analysis of 1352 adult inpatients at a tertiary care university hospital diagnosed with CDI between January 1st, 2011 and December 31st, 2014. Patient demographics, disease severity, antibiotic regimen, clinical outcomes, and primary and consultation services were recorded. A portion of this study was presented at DDW2016.

Results: Among 1352 hospitalized patients with CDI, 589 (44%) were managed according to guidelines. Stratifying by severity, the adherence rate (AR) for mild to moderate, severe, and severe complicated disease are 66%, 13%, and 11% respectively (P <0.01). Under-treatment rates for mild to moderate, severe, and severe complicated disease were 5%, 56%, and 90% respectively (P <0.01). AR was higher in patients admitted to university service compared to private service (51% vs 38%, P <0.01). The AR in patients for whom Infectious Diseases or Gastroenterology service was consulted was 36% and 31% respectively. All-cause mortality rate was significantly higher in guideline non-adherent group in general as compared to guideline adherent group (16.5% vs 10.2%, P <0.01). Ninety day readmission rate and length of hospital stay between guideline adherent and nonadherent groups were not significantly different; however, 90 day readmission rate was found to be a clinically important independent risk factor of mortality (OR 4.69, 95% CI, 2.01-10.93, P <0.01).

Conclusion: Mild to moderate CDI are often treated based on IDSA guidelines; however, a majority of patients diagnosed with either severe or severe complicated CDI are undertreated and this is associated with increased all-cause mortality. In addition, 90 day readmission was an independent risk factor of mortality. Future efforts should focus on education and reinforcement of guideline adherence in the treatment of CDI, particularly in patients with severe and severe complicated disease.