Clostridium Difficile Infection in the Intensive Care Unit: A Scoping Review.
CCCF ePoster library. Duan E. Nov 8, 2018; 233396; 73
Dr. Erick Duan
Dr. Erick Duan
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Introduction: Clostridium difficile infection (CDI) is of concern to patients and clinicians in the intensive care unit (ICU) where illness severity is high, CDI risk factors are common, and physiologic reserve is limited. However, the methodologies and findings of these studies have not been well characterized or summarized.

Objectives: To identify the extent, nature and design of available studies on CDI in the ICU and to identify gaps warranting further research. We focused on 4 domains of interest: 1. Incidence and prevalence of CDI in the ICU; 2. Risk factors for CDI the ICU; 3. Outcomes of patients with CDI in the ICU; 4. Poor prognostic factors in patients with CDI in the ICU.

Methods: We conducted a search of MEDLINE/EMBASE (inception to June 2015) using the terms: Clostridium difficile, pseudomembranous colitis, critically ill patients, and intensive care unit. Two reviewers independently screened, reviewed and collected data with discussion and consensus. We included studies of adults (>50% over 18y) in the ICU, with CDI (ICU-acquired, or pre-ICU CDI), or at risk for CDI. We included all study designs, excluding narrative reviews and case reports. We collected data based on our 4 objectives, using a common analytical framework. 

Results: We identified 1284 studies and included 47 studies (44 cohort [33 retrospective, 11 prospective], 1 randomized control trial and 2 case series). For CDI diagnosis, most studies used clinical criteria and a microbiological test (68%, n = 32), and fewer used microbiological testing only (31%, n=15); published diagnostic criteria were rarely used. Most studies used ELISA for microbiological tests (68%, n=32).


In 27 studies of incidence or prevalence, the pooled prevalence of CDI in the ICU was 1.8% (95% CI 1.7-1.9%, n=24). The incidence of ICU-acquired CDI was 1.3% (1.2-1.4%, n= 17). When using clinical criteria and a microbiological test, prevalence was 1.5% (1.4-1.6%, n=20), and using a microbiological test only, 9.3% (8.3-10.3%, n=4). The prevalence in mixed/medical ICU was 2.2% (2.0-2.7%, n=17) vs. subspecialty ICU 0.8% (0.6-0.9%, n=7).

In studies of risk factors for CDI (n=13), 5 studies performed multivariate analyses, and identified advanced age, female sex (2 studies), proton pump inhibitors, third generation cephalosporins, fluoroquinolones, blood transfusions, days of administration, and hospital length of stay (LOS) (1 study) as risk factors for CDI.

In studies of outcomes in ICU patients with CDI (n=9), 2 studies examined mortality with multivariate analysis and did not demonstrate an association; 3 studies examined ICU and hospital LOS, finding an association with increased hospital LOS (2 studies), and increased ICU LOS (1 study).

In studies of prognostic factors in ICU patients with CDI (n=7), 6 studies examined predictors for mortality with multivariate analysis, and identified age, shock (4 studies), APACHE II, and transfer from ward (2 studies). Other predictors were identified only in 1 study.

Conclusions: We found few multicentre studies on CDI in the ICU, with small sample sizes and mostly retrospective cohort designs. Prevalence or incidence of CDI varied based on definitions used. Studies of risk factors, outcomes, and prognostic factors were limited by small sample sizes and few multivariable analyses. More multicentre studies with rigorous methodology, standardized terminology and multivariable models are needed to inform our understanding of CDI during critical illness.


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