Evaluation of RISK Factors of Clostridium Difficile Associated Diarrhea (CDAD) in MEDICINE and Surgical Inpatients

Introduction: Clostridium difficile Associated Diarrhea (CDAD) is a leading cause of nosocomial diarrhea, creating a major economic burden in Health Care. At a major teaching tertiary care center, a preliminary epidemiological survey revealed a striking discrepancy in the distribution of nosocomial CDAD in Medicine (73.8%) and Surgery (8%). Thus, we proposed to compare the distribution of the risk factors for CDAD in Medicine and Surgical Services.

Methods: A retrospective random sampling review of 94 Medicine and 76 Surgery charts of patients discharged between March 2004-July 2006 was conducted. We studied the distribution of various risk factors for CDAD in Medicine and Surgery patients: age, length of stay (LOS), admission source(community vs.skilled nursing facilities-SNF), readmission to hospital within 90 days, discharge disposition, prior history of CDAD, albumin level, use of antibiotics and Proton Pump Inhibitors (PPIs), immunosuppression, chemotherapy and hemodialysis.

Results : Patients admitted to Medicine were significantly older than in Surgery (mean age:79.7 v.75.1, p<.001), though their LOS were similar (6.5 days v.5.1, p=0.178). There was a remarkable difference between admission sources, with SNF transfers accounting for 15.7% of medical admissions versus only 1.3% of surgical (p=.001). Similarly, 29.2% of Medicine patients were discharged to SNF compared to 9.2% of surgical patients (p=.001). Readmissions within 90 days accounted for 31.5% of Medicine patients, compared with 11.1% of Surgical patients (p=.002). Serum albumin levels were lower in Medicine (3.7g/dl) than in Surgery (3.9 g/dl, p=.045). Almost half (44.7%) of Medical patients were prescribed PPIs, compared to 37.1% of surgical patients (p=.022). Finally, antibiotics were prescribed to 47.9% of medical and 60% of surgical patients, most of whom receiving single dose prophylaxis (p<.001). Prior history of CDAD, immunosuppresion, chemotherapy and hemodialysis were not significant risk factors in either group.

Conclusion: These results support age, low serum albumin and use of PPIs as known risk factors for CDAD. In addition, this study outlines socio-demographic risk factors, namely the role of SNF for both admission and discharge sites, as strong predictors of CDAD.