Current definitions for severe C. difficile infection (CDI) are based on populations of Western countries. We examined the predicting performance of existing definitions in Taiwanese population and developed a new severity score.
We included adult patients who were admitted to China Medical University Hospital and had first-time positive C. difficile culture or toxin test during 2012 - 2016. The index date was the sampling date of the specimen. Data were pulled from the electronic medical records. The primary outcome was in-hospital death during the index admission. Variables that were significantly associated with in-hospital death in the bivariable analyses were included in a multivariable logistic regression model. We assigned weight for each variable using the adjusted odds ratio (aOR) and summed up the weights to obtain a severity score.
Of 544 patients, median age was 71 years old and 70 patients (12.9%) died during the index admission. Patients did not differ in: gender, age, prior infection (-30 to 0 day of index date), prior admission, prior anti-peptic ulcer medication use, index (-3 to 3 days) glucose and kidney function except for blood urea nitrogen (BUN). Variables included in the multivariable model were: complicated diabetes (aOR 2.0; 0.8 - 5.2), malignancy (2.0; 1.1 - 3.7), prior use of 2nd generation cephalosporins (1.8; 0.9 - 3.7), use of loperamide (1.8; 1.0 - 3.4) or probiotics within -14 to 14 days (2.4; 1.0 - 5.5), index white blood cell count (WBC) > 15,000 cells/uL(1.9; 1.0 - 3.6), index serum creatinine (sCr) ≥ 1.5 times premorbid level (1.1; 0.6 - 2.1), index BUN > 30 mg/dL (1.7; 0.9 - 3.5), and index BUN/sCr ratio > 20 (1.3; 0.7 - 2.5).
The severity score was significantly higher among patients who died during admission than those who survived (median 6 vs 4). A score of ≥ 4 was defined as severe. The performance of severity score was better than that of SHEA-IDSA or ESCMID definition (see figure below).
PPV = positive predictive value; NPV = negative predictive value.
Current guidelines use WBC, sCr increase, sCr, or albumin to define the severity of CDI. Our severity scoring system improved the predictive performance by adding novel indicators of comorbidities, BUN, BUN/sCr, and anti-diarrhea medications use.
H. Y. Chiang,
C. W. Chung, None
Y. C. Yeh, None
N. Tien, None
H. S. Lin, None
C. C. Kuo, None