Adherence to Treatment Guidelines for Incident Clostridium difficile Infection in Critically Ill Adults

Background:

Treatment guidelines for Clostridium difficle infection (CDI) based on severity define severe

CDI as leukocyte count greater than 15000/ul or serum creatinine (Cr) ratio greater than 1.5 times baseline.

Hypotension, shock, ileus and megacolon signify severe-complicated CDI. These metabolic

derangements and clinical syndromes are common among intensive care unit (ICU) patients

without CDI, thus increasing the potential difficulty in determining the severity and appropriate

treatment for CDI among ICU patients. We sought to evaluate adherence to treatment guidelines

in this population.

Methods:

Retrospective observational study of critically ill adults with incident CDI diagnosed 48 hours or more

after ICU admission, admitted to a tertiary care center between January 1, 2011 and December

31, 2013 was completed. Data on demographics, clinical details, laboratory values and

medications were abstracted.

Results:

Overall, 67 patients with median age 66 years (range 19-98), 58.2% males, median Charlson

Comorbidity score of 5 (range 0-15) and a median Apache III score of 42.5(range 14-115) on

ICU admission were included. Of these patients, 31(46.3%) did not have a baseline Cr and Cr at

ICU admission was used. There were 36 (53.7%) mild/moderate, 16 (23.9%) severe and 15

(22.4%) severe complicated CDI patients. The majority (n=40, 59.7%) were treated with

metronidazole, 8 (11.9%) with vancomycin and 17(25.4%) with both medications.

Overall 36 (55.4%) had treatment appropriate for clinical severity, however 29 (44.6%) did not,

2 received no treatment secondary to death or transition to comfort cares. Two patients required

colectomy (1 with appropriate treatment, 1 without). Eleven patients had a subsequent positive

CDI at least 14 days after initial testing and of these, 5 had severity discordant therapy.

Conclusion:

This study highlights that determination of attributable severity of illness among critically ill

patients with CDI is difficult to assess by current guidelines definitions and clinician treatment

may be discordant with these definitions in many cases. Further study is necessary to develop

appropriate severity scoring systems and treatment decision algorithms for CDI among the

critically ill.