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Increased Mortality in Megacolon C. diff Patients


NEW YORK - Health care professionals should be highly suspicious of megacolon in Clostridium difficile-infected patients and have a low threshold for transferring infected patients to intensive care units, Veterans Affairs researchers warn.

"The incidence of Clostridium difficile-associated megacolon has nearly tripled and mortality has nearly doubled over the past decade," Dr. SreyRam Kuy from the Overton Brooks VA Medical Center in Shreveport, Louisiana, said by email.

"It could be argued that this increased incidence may be due in part to improvements in detection of Clostridium difficile," she said. "However, this increase over the past decade . . . correlates with prior work by the Agency for Healthcare Research and Quality, which showed a 74% increase in the overall number of hospital discharges with Clostridium difficile infections from 1993-2001, in the decade prior to our study."

Dr. Kuy and colleagues analyzed records in the Nationwide Inpatient Sample (2000-2010) and identified patients with both C. difficile infection and megacolon.

They identified 28,219 cases of C. difficile infection, or 0.38% of all hospitalized patients, in 2000. That grew to more than 68,600 cases, or 0.88% of hospitalized patients, in 2010.

While the overall incidence of megacolon remained steady at 0.02% of hospitalized patients from 2000 to 2010, the rate of megacolon cases tied to C. diff infection increased from 3.61% in 2000 to 9.39% in 2010 (p<0.05).

"Compared with patients with megacolon but without C. difficile infection, patients with C. difficile-associated megacolon are significantly older, are more likely to have an urgent or emergent admission, are more likely to be admitted from the emergency department or transferred from another hospital, and are more likely to be treated at large, urban, teaching hospitals," the researchers write in an article online Oct. 7 in JAMA Surgery.

They report that the mean length of hospital stay for patients with C. difficile-associated megacolon was 16.13 days, the mean cost of hospitalization came to $41,968, and 50.7% required transitional care after hospital discharge. The mortality among these patients went up from 13.56% in 2000 to 24.45% in 2010, and peaked at 30.03% in 2007 (p<0.05).

"The rise in mortality is also alarming," Dr. Kuy said. "Potentially, this rise in mortality could be attributed to changes in virulence of Clostridium difficile strains, though we are unable to determine this due to limitations of the dataset utilized for this research. Other factors that can affect mortality are antibiotic regimen, severity of disease, physical exam findings, immunosuppression, presence of end organ failure, patient frailty status, APACHE (Acute Physiology and Chronic Health Evaluation) score, signs of sepsis, and leukocytosis, which have been identified as factors associated with mortality in prior published reports."

"This study draws attention to the tremendous burden of Clostridium difficile on patient mortality, health care costs and resources, transitional care utilization, and the extremely important need for aggressive prevention of this iatrogenic disease," she concluded.

The authors reported no funding or disclosures.

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