Abstract
Background
Clostridium difficile infection (CDI) is a leading cause of morbidity and mortality in a hospitalized patient. The incidence and severity of nosocomial CDI have increased significantly since the year 2000. Solid-organ transplant recipients (SOT) are at high risk for CDI for multiple reasons including impaired defense mechanisms from immunosuppression, perioperative antibiotic use, and organ failure. For the past decade, there has been the advance modality of diagnosis and treatments for CDI including early detection of toxin, novel antibiotics, and fecal microbiota transplantation. With the innovative measurements and the effort of antibiotic stewardship, the recent study show improvement of mortality in hospitalized CDI; however, there is still lack of such evidence among SOT patients. Therefore, it would be beneficial to scrutinize the prevalence and outcomes of CDI among SOTs with the most current available nationwide database.
Methods
Our study utilized the 2015 and 2016 National Inpatient Sample (NIS). It is the largest publicly available all-payer inpatient healthcare database in the United States, yielding national estimates of hospital inpatient stays. Patients with history or undergoing SOT transplant procedure who were hospitalized in 2015 and 2016 NIS database were included in our study. We included heart, lung, liver, intestinal, kidney, pancreas, or at least one of these organs transplanted in our definiton of SOT. History of organ tranplants and CDI were extracted by using ICD-9-CM and ICD-10-CM from discharged diagnosis. Baseline characteristic include age, gender, race, median household income were collected. Confounding includes comorbidities which were calculated into charlson comorbidity index (CCI) and discharge diagnosis of pneumonia and urinary tract infection. Primary outcomes include in-patient mortality, hospital length of stay and total hospital charges. Secondary outcomes include transplant failure or rejection, colectomy and disposition of patients. Multivariable logistic regression was used for the adjusted analysis of the primary and secondary outcomes include all confounders and significant covariates. All reported CIs were two-sided 95% intervals, and tests were done at the two-sided 5% significance level. Stata v14.2 (Stata Corp, College Station, Texas) was utilized for all analyses.
Results
A total of 107,461 discharges of SOTs in 2015–2016 NIS database were included in our study. The mean age was 53 years (SD 17) and 45,666 (42%) were female. History of kidney transplant was found to be the most common (55%) and history of liver tranplants was the second most common (19%) among our population.The incidence of CDI was 3,626 (3.37%) among SOTs. Factors associated with CDI include age (4% increasing of odds for 10-year increment in age), female (OR 1.2; 95% CI 1.16–1.34), history of heart transplant (OR 1.28; 95% CI 1.11–1.48), kidney transplant (OR 0.98; 95% CI 0.82–0.97), UTI (OR 1.65; 95% CI 1.50–1.81) and pneumonia (OR 1.24;; 95% CI 1.122- 1.38). CDI associated with higher inpatient mortality (OR 1.85, 95% CI 1.56–2.20, P < 0.01), longer length of hospital stay (mean difference 5.07 days, 95% CI 4.43–5.71, P < 0.01) and higher total hospital charges (mean difference 43,958 dollars, P < 0.01). Furthermore, SOTs with CDI had higher risk of transplant complication (OR1.67, 95% CI 1.50–1.87, P < 001) and increase risk of colectomy (OR 2.36, 95% CI 1.50–3.72). Those who had CDI were less likely to be discharged home when compare to non-CDI (OR 0.53, 95% CI 0.49–0.58, P < 0.01).
Conclusion
Our study found that CDI associated with significant overall worse outcomes among hospitalized solid-organ transplant patients. Multicenter prospective study is considered as a future direction to evaluate the impact to healthcare. Despite the improvement of overall mortality of CDI in general population in the United States from prior study, CDI in SOTs remains problematic. More attention is needed in this particular field.
Disclosures
All authors: No reported disclosures.
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