IBD and C. Difficile Make Deadly Combination
By Michael Smith, Senior Staff Writer, MedPage Today
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco
September 26, 2007
MILWAUKEE, Sept. 26 -- A Clostridium difficile infection sharply increases the risk of death for patients with underlying inflammatory bowel disease, researchers here said.
Action Points
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* Explain to interested patients that disease associated with Clostridium difficile has been increasing in incidence for several years, and is often associated with mortality in the hospital setting.
* Note that this study suggests that C. difficile disease is especially dangerous in patients with inflammatory bowel disease.
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People admitted to the hospital with a combination of C. difficile and either Crohn's disease or ulcerative colitis were nearly five times as likely to die as those admitted for inflammatory bowel disease alone, according to David Binion, M.D., and colleagues at Wisconsin College of Medicine.
They were also more likely to die than patients admitted with just C. difficile associated disease, Dr. Binion and colleagues reported in the online issue of Gut.
Doctors should engage in "prudent use of antibiotics" patients with inflammatory bowel disease to reduce the incidence of C. difficile disease, the researchers said.
Their findings came from an analysis of the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample for 2003. The sample for that year covered 37 states, 994 hospitals of all sizes and types, and more than 38 million discharges.
The investigators found that the discharge diagnosis was both C. difficile and inflammatory bowel disease in 2,804 cases, C. difficile alone in 44,400 cases, and inflammatory bowel disease alone in 77,366 cases.
A multivariate analysis showed that:
* Patients with both conditions were significantly more likely (at P<0.05) to die in the hospital than those with inflammatory bowel disease alone. The adjusted odds ratio was 4.7, with a 95% confidence interval from 2.9 to 7.9.
* Patients with both conditions were twice as likely to die as those with C. difficile associated disease alone. The adjusted odds ratio was 2.2, with a 95% confidence interval from 1.4 to 3.4, which was also significant at P<0.05.
The analysis also showed that -- compared with patients with inflammatory bowel disease alone - those with both conditions had a longer hospital stay (3 days on average), higher hospitalization costs ($11,406 on average), and higher rates of lower GI endoscopy.
Patients with both conditions were half as likely, however, to have bowel surgery as those with inflammatory bowel disease alone (the adjusted odds ratio was 0.6) but they were much more likely to have surgery than those admitted with C. difficile alone (the odds ratio was 6.6).
Interestingly, having C. difficile and ulcerative colitis was more dangerous than C. difficile and Crohn's disease. Specifically:
* 5% of those with ulcerative colitis and coexisting C. difficile died in the hospital, compared with 3% of those with Crohn's and C. difficile. The difference was significant at P=0.01.
* Ulcerative colitis patients also had higher rates of lower GI endoscopy - 56% versus 46.9%, which was significant at P<0.01.
* And they had higher rates of bowel surgery -- 10.4% versus 8%, which was significant at P=0.04.
Among the study's strengths, the researchers said, is the fact that it uses a large nation-wide sample. On the other hand, the researchers were unable to adjust for the severity of underlying inflammatory bowel disease.
Also, they said, it is possible that some patients classified as having inflammatory bowel disease alone also had mild C. difficile disease, but were not tested for the toxin, which would reduce the magnitude of the associations.
The Healthcare Cost and Utilization Project, maintained by the Agency for Healthcare Research and Quality, provided data for this study. The authors reported no conflicts.
Additional General Infectious Disease Coverage
Primary source: Gut
Source reference:
Ananthakrishnan AN et al. "Excess hospitalisation burden associated with Clostridium difficile in patients with inflammatory bowel disease." Gut 2007; doi: 10.1136/gut.2007.128231.
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