Outbreak of severe Clostridium difficile-associated colitis with MOF in Quebec intensive care units: first analysis in Sherbrooke ICUs

Introduction

Recent reports suggest that Clostridium difficile colitis (CDAC) may be evolving into a more severe disease [1]. Over the past 2 years, an increased case fatality associated with CDAC was noted as the admission rate to our adult tertiary ICUs for this entity increased in a context of inhospital outbreak. This CDAC outbreak occurred in a 682-bed regional hospital in Quebec, Canada. All cases admitted to ICUs with a diagnosis of life-threatening CDAC were systematically reviewed over a 20-month period (between 1 January 2003 and 21 August 2004). The following is a retrospective statistical analysis.

Results

Until now, 41 cases of CDAC requiring intensive care monitoring and treatment have been collected; 53.7% were of male sex and the median age was 78 years (25th–75th %: 71–82). The Charlson morbidity index was calculated for each patient for a median of 4 (25th–75th %: 3–6). Patients were generally exhibiting a sepsis profile with high-grade fever (median 39.20°C, 25th–75th %: 38.7–39.4°C), and high leukocyte counts (median 28.15 × 10⁹/l, 25th–75th %: 20.8–43.7) at some time during the ICU stay. Serum creatinine levels were elevated (median 204 μmol/l, 25th–75th %: 139–292 μmol/l). Shock status was diagnosed in 83% of the patients and catecholamines were mandatory in 53.7% of the time for a mean duration of 3.4 days (± 0.47) in addition to volume resuscitation. Patients were resuscitated during the first 72 hours following their ICU admission with a mean of 10.7 cm³ (± 986 cm³) of crystalloid solution, 586 cm³ Pentastarch solution (± 92 cm³) and 231 cm³ of 25% albumin (± 75 cm³). Upon entry to the ICUs, the APACHE II score was calculated and the median obtained was of 24 (predicted mortality rate 49.7%). Furthermore, the SOFA score was also obtained upon entry, 48 hours after admission and every subsequent week. In the first 48 hours, the total SOFA score increased in 26.8% and decreased in 31.7% of the patients. Thirty-two percent of the population reached the maximum cardiovascular SOFA score of 4 (i.e. norepinephrine > 0.1 μg/kg/min). Twenty-two percent of patients went to the operating room.

The overall observed mortality rate was 49%. An APACHE II score upon entry of 22 or more and an age greater than 75 were both associated with higher mortality with an adjusted odds ratio (OR) of 7.6 (95% confidence interval [CI] 1.6–33.9, P = 0.01) and 4 (95% CI 1.06–15,1 P = 0.07). A trend toward higher mortality was observed in patients with an increasing SOFA score within the first 48 hours of admission (OR 4.55, 95% CI 0.91–22.6, P = 0.1) and high serum lactate levels (OR 18.8, 95% CI 0.97–362, P = 0.03 for lactates > 6.5) but no trends were noted regarding the Charlson comorbidity index, the decision of surgery (colectomy for bowel perforation vs refractory shock) or catecholaminergic drug use.

Discussion

This case review reveals the existence of an outbreak of CDAC with increasing case fatality and worsening outcome in Quebec. Epidemiologic data will help in defining more efficient preventive measures directed toward this nosocomial entity and allowing early recognition in order to thwart severe illness.