2008 Annual Meeting Abstracts

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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)
Factor		Mortality, 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
Bands	>=10% <10%	53 (40.5%) 16 (23.5%)	2.8 [1.3 - 6.5]	0.01
Vasopressors	Yes No	48 (52.2%) 21 (19.6%)	4.0 [1.9 - 8.5]	0.0004
Intubation	Yes No	45 (52.9%) 24 (21.1%)	4.7 [2.1 - 10.5]	0.0001
Oral vancomycin	Yes No	19 (21.6%) 50 (45.0%)	0.25 [0.11- 0.55]	0.0006
Colectomy	Yes No	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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