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2008 Annual Meeting Abstracts

Fulminant Clostridium Difficile Colitis: Patterns of Care and Predictors of Mortality
Elizabeth A. Sailhamer, MD1, Katherine Carson, BS1, Yuchiao Chang, Ph.D.2, Nikolaos Zacharias, MD1, Konstantinos Spaniolas, MD1, Malek Tabbara, MD1, Hasan B. Alam, MD1, Marc A. DeMoya, MD1, George C. Velmahos, MD1.
1Massachusetts General Hospital, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Boston, MA, USA, 2Massachusetts General Hospital, Department of Medicine, Division of Biostatistics, Boston, MA, USA.

Objective: To identify predictors of mortality and the need for colectomy among patients with fulminant Clostridium difficile colitis (FCDC).
Design:Retrospective study
Setting: Academic tertiary referral center
Patients: We reviewed the records of 4,796 patients with CDC admitted from 1996-2007, and identified 199 (4.1%) with FCDC, as defined by the need for colectomy or admission to the ICU for CDC.
Interventions: None
Main Outcome Measures: Risk of inpatient mortality was determined by multivariate analysis according to clinical predictors, colectomy, and medical team.
Results: In-hospital mortality for FCDC was 34.7%. Independent predictors of mortality included: 1) age >= 70 years, 2) severe leukocytosis or leukopenia (>=35,000 or <4,000 cells/mm3) or bandemia (bands >=10%), and 3) cardiorespiratory failure (intubation or vasopressors). When all three factors were present, mortality was 57.1%; when all three were absent, it was 0%. Patients who underwent colectomy had a trend towards decreased mortality (OR: 0.49 [0.21-1.1], p=0.085). Vancomycin was also protective. Among patients admitted primarily for FCDC, care on the surgical service compared to the non-surgical services resulted in a higher rate of operation (85.1% vs 11.2%, p<0.0001) and lower mortality (12.8% vs 39.3%, p=0.001). Patients admitted directly to surgery had a shorter interval from admission to operation (0 vs. 1.7±0.5 days, p = 0.001).
Table: Independent predictors of mortality in FCDC (n=199)
FactorMortality, n (%)OR [95%CI]p-value
Age>=70 years
<70 years
47 (40.2%)
22 (26.8%)
2.2 [1.0 - 4.8]0.04
WBC>=35 or <4 K/mm3
>=4 & <35 K/mm3
38 (46.3%)
31 (26.5%)
4.2 [1.9 - 9.1]0.0003
53 (40.5%)
16 (23.5%)
2.8 [1.3 - 6.5]0.01
48 (52.2%)
21 (19.6%)
4.0 [1.9 - 8.5]0.0004
45 (52.9%)
24 (21.1%)
4.7 [2.1 - 10.5]0.0001
Oral vancomycinYes
19 (21.6%)
50 (45.0%)
0.25 [0.11- 0.55]0.0006
24 (32.0%)
45 (36.3%)
0.49 [0.21 - 1.1]0.085

Conclusions: Despite awareness and treatment, FCDC remains a highly lethal disease. Reliable predictors of mortality exist and should be used to prompt aggressive surgical intervention. Survival is higher in the surgical than the non-surgical services, possibly because of more frequent and earlier operations.


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