Elsevier

Journal of Infection

Volume 57, Issue 6, December 2008, Pages 435-440
Journal of Infection

The acquisition and outcome of ICU-acquired Clostridium difficile infection in a single centre in the UK

https://doi.org/10.1016/j.jinf.2008.10.002Get rights and content

Summary

Background

The clinical course and outcome of Clostridium difficile infection (CDI) in the intensive care unit (ICU) setting have been reported in a small number of studies in the US and Canada. However, no such study has been reported in the UK. Therefore, we aimed to study the acquisition rate and outcome of ICU-acquired CDIs in our unit.

Method

Patient admissions to the ICU and nosocomial infection databases from April 2004 to April 2007 were reviewed to identify study groups, followed by retrospective case note review. Patients who acquired CDI prior to ICU admission were excluded.

Results

Sixty-two patients (31 males) who acquired CDI during their ICU stays were included in our study. The acquisition rate of CDI ranged from 1.52 to 4.78% per year. The median APACHE II score was 18, and the median interval between ICU admission and acquisition of CDI was 7 days. The median ICU stay was 16 days. Of the 62 patients, 13 (20.97%) died in the ICU. Of the 49 patients who were discharged, 41 were discharged ultimately from the hospital. Thus, the overall mortality attributable to CDI acquired in the ICU was 33.87%, compared to the average baseline mortality of 29% in our unit. Univariate analysis showed that increasing age (p = 0.004), APACHE II score (p = 0.007), and male gender (p = 0.05) were significantly associated with ICU mortality in patients who acquired CDI in the ICU. Multivariate analysis showed that only increasing age (p = 0.031; OR 1.141, CI 1.013–1.287) was significantly associated with higher ICU mortality.

Conclusion

Patients admitted to the ICU have a moderate risk of acquiring CDI. There is a small increase in mortality observed in patients who acquired CDI in the ICU. Increasing age is an independent predictor associated with mortality.

Introduction

According to the UK Department of Health, the healthcare-associated infections encompass any infection by any infectious agent acquired as a consequence of a person's treatment by the NHS or which is acquired by a healthcare worker in the course of their NHS duties.1 Undoubtedly, CDI has become one of the most frequent causes of healthcare-associated diarrhoea. The number of death certificates mentioning Clostridium difficile increased each year in England and Wales between 1999 and 2006.2

The ICU represents the most frequently identifiable source of nosocomial infections within the hospital, with nosocomial infection and antimicrobial resistance rates several- fold higher than that in the general hospital setting.3, 4 Particularly, CDI in the ICU is a major problem because most patients in the ICU require antibiotic treatment, where use of multiple agents or prolonged treatment is common. Hence, ICU patients are invariably vulnerable to CDI. Kuijper et al.5 reported that diarrhoea caused by Clostridium difficile occurs more frequently in patients who have been submitted to surgery and in patients placed in the ICU.

Despite this, relatively little is known about the acquisition rate of CDI and its impact in ICU setting, especially among UK hospitals. Most studies on CDI in ICU settings have been from United States or Canadian hospitals.6, 7, 8, 9, 10, 11 Even so, the true acquisition rate of CDI in the ICU setting is unclear from these studies.

Therefore, the objectives of this study were to evaluate the acquisition rate and the impact of nosocomial CDI with its related morbidity and mortality in the ICU setting. We also aimed to evaluate the predictors for mortality among patients who acquired CDI in the ICU.

Section snippets

Study setting and design

The University Hospital of North Staffordshire is a tertiary care referral centre comprised of two hospital sites less than a mile from each other, the City General Hospital and the Royal Infirmary. Each hospital has an adult general ICU, which is Ward 15, City General ICU, and the Multiple Injuries Unit (MIU) at the Royal Infirmary. These two ICUs, which formed the settings for our study, serve adult trauma patients, and medical and surgical patients across various specialties.

Ward 15 is an

Results

There were 1852 patients admitted to ICUs during the 3-year study period. From April 2004 to March 2005, 23 patients (3.92%) out of 587 total ICU admissions acquired CDI. In the subsequent year, only 10 patients (1.52%, of 658 total admissions) acquired CDI. However, there was an increase in the number of patients who acquired CDI from April 2006 to March 2007, during which 29 patients out of 607 admissions (4.78%) were affected. Therefore, these 62 patients contracted CDI in the ICU and were

Discussion

Clostridium difficile was first described in the 1930s by Hall et al.14 It is a spore-forming, anaerobic, gram-positive bacillus which Bartlett et al.15, in 1978, established was the agent responsible for antibiotic-associated pseudomembranous colitis. Clostridium difficile is generally resistant to penicillins and cephalosporins, while most anaerobic bacteria of the intestinal flora are susceptible. So, administration of these drugs provides excellent conditions for overgrowth of Clostridium

Conclusion

It is paramount to perform infection surveillances regularly as these are important fundamentals for the prevention and management of nosocomial infections in any ICU. Our study clearly documents a marked mortality rate associated with CDI acquisition in the ICU setting. The results of this study should provide a reference point for greater and continuous surveillance in order to implement effective preventive measures. A multi-disciplinary team consisting of colleagues in pharmacy, infection

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