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Kuy S, Jenkins P, Romero RAL, Samra N, Kuy S. Increasing Incidence of and Increased Mortality Associated With Clostridium difficile–Associated Megacolon. JAMA Surg. 2016;151(1):85–86. doi:10.1001/jamasurg.2015.2677
The symptoms of Clostridium difficile infection range from diarrhea to the rare, but potentially fatal, toxic megacolon. The aim of this study is to determine the changes in the incidence and outcomes of C difficile–associated megacolon over a 10-year period.
Using the Nationwide Inpatient Sample (2000-2010) and International Classification of Diseases, Ninth Revision (ICD-9) codes, we identified patients with both C difficile infection and megacolon. Patients without both diagnoses were excluded. The study cohort included patients who were managed with surgery and those who were managed without surgery. This study used deidentified data and is exempt from institutional review board approval. The outcome measures were length of stay, inflation-adjusted cost of hospitalization, transitional care needs, and in-hospital mortality.1 Analyses were performed with χ2 tests and analysis of variance. P > .05 was considered statistically significant.
In 2000, there were 28 219 cases of C difficile infection (0.38% of all hospitalized patients), and by 2010, there were 68 645 cases (0.88% of all hospitalized patients). The overall incidence of megacolon among all hospitalized patients remained 0.02% from 2000 to 2010. In contrast, the percentage of cases of megacolon due to C difficile infection was 3.61% in 2000 and 9.39% in 2010 (P < .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 be treated at large, urban, teaching hospitals (Table 1). Among patients with C difficile–associated megacolon, the mean (SD) length of hospital stay was 16.13 (16.55) days, the mean (SD) cost of hospitalization was $41 968 ($51 518), 50.7% required transitional care after hospital discharge, and the overall in-hospital mortality rate was 24.45% (Table 2). When examining mortality trends over the decade, the mortality rate associated with C difficile–associated megacolon increased from 13.56% in 2000 to 24.45% in 2010, with a peak of 30.03% in 2007 (P < .05).
The incidence of C difficile–associated megacolon has nearly tripled, and the mortality rate associated with this condition has nearly doubled, over the past decade. This increased incidence could be due in part to improvements in the detection of C difficile. However, this increase correlates with the work performed by the Agency for Healthcare Research and Quality, which showed a 74% increase in the overall number of hospital discharges of patients with C difficile infection from 1993 to 2001.2
The increase in mortality could be attributed to changes in the virulence of the C difficile strains, although we are unable to determine this owing to the limitations of the data set. We were unable to examine variables such as antibiotic regimen, severity of disease, physical examination findings, immunosuppression, presence of end-organ failure, patient frailty status, Acute Physiology and Chronic Health Evaluation score, and signs of sepsis and leukocytosis, which have been identified as factors associated with mortality in prior published reports.3 Another limitation of this database is the use of ICD-9 codes rather than the use of clinical and radiographic criteria, which are not available in this database. The mortality rates associated with C difficile–associated megacolon have been reported to range from 38% to 80%, with early diagnosis crucial in improving mortality, but they are based on case studies and case series.4-6 The Nationwide Inpatient Sample database is limited to single admissions; further study is needed to examine long-term survival among these patients.
By using a national data set spanning a decade (2000-2010), we were able to study the largest group to date. This study draws attention to the tremendous burden of C difficile on patient mortality, health care costs and resources, and transitional care and the need for aggressive prevention of this iatrogenic disease. Despite the rarity of C difficile–associated megacolon, our findings suggest that health care professionals should have a heightened suspicion of megacolon in patients with C difficile infection and a lower threshold for transferring infected patients to intensive care units, where goal-directed resuscitation is most feasible.
Corresponding Author: SreyRam Kuy, MD, MHS, Surgical Service, The Center for Innovations in Quality, Outcomes, and Patient Safety, Overton Brooks Veterans Affairs Medical Center and Department of Surgery, Louisiana State University School of Medicine, 1501 Kings Hwy, Shreveport, LA 71130 (firstname.lastname@example.org).
Published Online: October 7, 2015. doi:10.1001/jamasurg.2015.2677.
Author Contributions: Dr SreyRam Kuy had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: SreyRam Kuy, SreyReath Kuy.
Acquisition, analysis, or interpretation of data: SreyRam Kuy, Jenkins, Romero, Samra.
Drafting of the manuscript: SreyRam Kuy.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: SreyRam Kuy.
Administrative, technical, or material support: SreyRam Kuy, SreyReath Kuy.
Study supervision: SreyRam Kuy, Jenkins, Samra, SreyReath Kuy.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This paper was presented at the 39th Annual Meeting of the Association of VA Surgeons; May 4, 2015; Miami Beach, Florida.