A possible association between statin use and improved Clostridioides difficile infection mortality in veterans.

Clostridioides difficile infection (CDI) is the most common cause of nosocomial diarrhea and places a significant burden on patients and the health care system. Statins could lead to improvements in CDI clinical response due their pleiotropic effects, including immunomodulatory and lipid-lowering effects; however, few studies have assessed this association. The primary objective of this study was to compare CDI health outcomes in statin users and non-users in a national cohort of patients. This was a retrospective cohort study of all adult CDI patients receiving care from the Veterans Health Administration from 2002 to 2014. Patients were divided into two groups based on statin exposure 90 days prior to and during their first CDI encounter. CDI health outcomes, including mortality and CDI recurrence, were compared using a propensity-score matched cohort of statin users and non-users and multivariable logistic regression. A total of 26,149 patients met study inclusion criteria, of which 173 statins-users and 173 non-users were propensity score matched. Thirty-day mortality was significantly lower among statins users with CDI (12.7%) compared to non-users (20.2%) (aOR 0.34; 95% CI 0.16-0.72). Sixty-day CDI recurrence was non-significantly lower among statin-users (9.0%) compared to non-users (16.6%) (aOR 0.68; 95% CI 0.29-1.59). In this nationally-representative study of veterans with CDI, statin use was associated with lower 30-day mortality compared to non-use. Statin use was not associated with 60-day CDI recurrence.

Derivation and Validation of a Clostridium difficile Infection Recurrence Prediction Rule in a National Cohort of Veterans.

STUDY OBJECTIVE: Prior studies have identified risk factors for recurrent Clostridium difficile infection (CDI), but few studies have integrated these factors into a clinical prediction rule that can aid clinical decision-making. The objectives of this study were to derive and validate a CDI recurrence prediction rule to identify patients at risk for first recurrence in a national cohort of veterans. DESIGN: Retrospective cohort study. DATA SOURCE: Veterans Affairs Informatics and Computing Infrastructure. PATIENTS: A total of 22,615 adult Veterans Health Administration beneficiaries with first-episode CDI between October 1, 2002, and September 30, 2014; of these patients, 7538 were assigned to the derivation cohort and 15,077 to the validation cohort. MEASUREMENTS AND MAIN RESULTS: A 60-day CDI recurrence prediction rule was created in a derivation cohort using backward logistic regression. Those variables significant at p<0.01 were assigned an integer score proportional to the regression coefficient. The model was then validated in the derivation cohort and a separate validation cohort. Patients were then split into three risk categories, and rates of recurrence were described for each category. The CDI recurrence prediction rule included the following predictor variables with their respective point values: prior third- and fourth-generation cephalosporins (1 point), prior proton pump inhibitors (1 point), prior antidiarrheals (1 point), nonsevere CDI (2 points), and community-onset CDI (3 points). In the derivation cohort, the 60-day CDI recurrence risk for each score ranged from 7.5% (0 points) to 57.9% (8 points). The risk score was strongly correlated with recurrence (R2  = 0.94). Patients were split into low-risk (0-2 points), medium-risk (3-5 points), and high-risk (6-8 points) classes and had the following recurrence rates: 8.9%, 20.2%, and 35.0%, respectively. Findings were similar in the validation cohort. CONCLUSION: Several CDI and patient-specific factors were independently associated with 60-day CDI recurrence risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were strongly correlated with CDI recurrence. This clinical prediction rule can be used by providers to identify patients at high risk for CDI recurrence and help guide preventive strategy decisions, while accounting for clinical judgment.

Shift to community-onset Clostridium difficile infection in the national Veterans Health Administration, 2003-2014.

BACKGROUND: Clostridium difficile infection (CDI) occurs frequently in inpatient settings; however, community-onset cases have been reported more frequently in recent years. This study evaluated hospital-onset and community-onset CDI in the national Veterans Health Administration (VHA) population over a 12-year period. METHODS: This was a retrospective cohort study of all adult VHA beneficiaries with CDI between October 1, 2002, and September 30, 2014. Data were obtained from the Veterans Affairs Informatics and Computing Infrastructure. CDI was categorized into community-associated CDI (CA-CDI); community-onset, health care facility-associated CDI; and health care facility-onset CDI (HCFO-CDI). Each type was described longitudinally and was assessed as an independent risk factor for health outcomes using multivariable logistic regression. RESULTS: Overall, 30,326 patients with a first CDI episode were included. HCFO-CDI was the predominant type (60.2%), followed by CO-HCFA-CDI (20.6%) and CA-CDI (19.2%). The proportion of patients with HCFO-CDI decreased from 73.5% during fiscal year 2003 to 53.2% during fiscal year 2014, whereas CA-CDI increased from 8.3% to 26.7%. HCFO-CDI was a positive predictor of severe CDI (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.59-1.84) and 30-day mortality (OR, 1.46; 95% CI, 1.32-1.61), but a negative predictor of 60-day recurrence (OR, 0.41; 95% CI, 0.37-0.46). CONCLUSIONS: HCFO-CDI was the predominant CDI type. The proportion of patients with CA-CDI increased and HCFO-CDI decreased in recent years. Patients with HCFO-CDI experienced higher rates of severe CDI and mortality.

National epidemiology of initial and recurrent Clostridium difficile infection in the Veterans Health Administration from 2003 to 2014.

INTRODUCTION: Prior studies demonstrated marked increases in Clostridium difficile infection (CDI) in the United States (U.S.) in recent years. The objective of this study was to describe the epidemiology of initial and recurrent CDI in a national Veterans Health Administration (VHA) cohort over a 12-year period. METHODS: This was a retrospective cohort study of all adult VHA beneficiaries with CDI (ICD-9-CM code 008.45) plus a positive CDI stool test between October 1, 2002 and September 30, 2014. Data were obtained from the VA Informatics and Computing Infrastructure. Recurrence was defined as a second ICD-9-CM code plus a new course of CDI therapy following a minimum three-day gap after the initial therapy was completed. CDI incidence and outcomes were presented descriptively and longitudinally. RESULTS: Overall, 30,326 patients met study inclusion criteria. CDI incidence increased from FY 2003 (1.6 per 10,000) to FY 2013 (5.1 per 10,000). Thereafter, CDI incidence decreased through FY 2014 (4.6 per 10,000). A total of 5,011 patients (17%) experienced a first recurrence and, of those, 1,713 (34%) experienced a second recurrence. Recurrence incidence increased 10-fold over the study period, from (0.1 per 10,000) in FY 2003, to (1.0 per 10,000) in FY 2014. Overall, 30-day mortality and median hospital length of stay (LOS) decreased among initial episodes over the study period. Mortality was higher for initial episodes (21%) compared to first recurrences (11%) and second recurrences (7%). Median hospital LOS was longer for first episodes (13 days) compared to first (9 days) and second recurrences (8 days). CONCLUSIONS: Initial and recurrent CDI episodes increased among veterans over a 12-year period. Outcomes, such as mortality and hospital LOS improved in recent years; both of these outcomes are worse for initial CDI episodes than recurrent episodes.

Clostridium difficile infection health disparities by race among hospitalized adults in the United States, 2001 to 2010.

BACKGROUND: Recognition of health disparities in Clostridium difficile infection (CDI) is an initial step toward improved resource utilization and patient health. The purpose of this study was to identify health disparities by black vs. white race among hospitalized adults with CDI in the United States (U.S.) over 10 years. METHODS: This was a retrospective analysis of the U.S. National Hospital Discharge Surveys from 2001 to 2010. Eligible cases included adults with an ICD-9-CM code for CDI (008.45). Patients with missing race or "other race" were excluded. The primary outcome, CDI incidence, was calculated as CDI discharges per 1,000 total discharges. Data weights were used to determine national estimates. Secondary outcomes included in-hospital mortality, hospital length of stay (LOS), and severe CDI. Comparisons were made using bivariable analyses. Race was assessed as an independent risk factor for CDI outcomes using logistic regression or proportional hazards models. RESULTS: These data represent 1.7 million CDI discharges, where 90 % of patients were identified as white and 10 % black. Blacks differed from whites with respect to all baseline characteristics (p <0.0001). CDI incidence was significantly higher in whites compared to blacks (7.7/1,000 discharges vs. 4.9/1,000 discharges, p < 0.0001). Blacks had higher mortality (7.4 % vs. 7.2 %, p < 0.0001), LOS >7 days (57 % vs. 52 %, p < 0.0001), and severe CDI (24 % vs. 19 %, p < 0.0001). In multivariable analyses, black race was a positive predictor of mortality (OR 1.12, 95 % CI 1.09-1.15) and severe CDI (OR 1.09, 95 % CI 1.07-1.11), and negative predictor for hospital LOS (OR 0.93, 95 % CI 0.93-0.94). CONCLUSIONS: CDI incidence was higher for white patients; however, black race was independently associated with mortality and severe CDI.

Synthetic cannabinoid hyperemesis resulting in rhabdomyolysis and acute renal failure.

Synthetic cannabinoid usage has increased in the past decade. Concurrently, emergency management of associated adverse effects due to synthetic cannabinoid usage has also risen. Reported toxicities include psychosis, seizures, cardiotoxicity, acute kidney injury, and death. While cannabis was first described as a cause of acute hyperemesis in 2004, a more recent case series also describes the association between cannabinoid hyperemesis and risk of acute renal failure. Synthetic cannabinoids have also been reported to cause acute hyperemesis and acute renal failure; however, the risk of rhabdomyolysis-induced renal failure has yet to be elucidated. In this article, we report the first known case of synthetic cannabinoid hyperemesis leading to rhabdomyolysis and acute renal failure.

Regional and seasonal variation in Clostridium difficile infections among hospitalized patients in the United States, 2001-2010.

BACKGROUND: This study identified national regional and seasonal variations in Clostridium difficile infection (CDI) incidence and mortality among hospitalized patients in the United States over a 10-year period. METHODS: This was a retrospective cohort study of the U.S. National Hospital Discharge Survey from 2001-2010. Eligible cases had an ICD-9-CM discharge diagnosis code for CDI (008.45). Data weights were used to derive national estimates. CDI incidence and mortality were presented descriptively. Regions were as defined by the U.S. Census Bureau. Seasons included the following: winter (December-February), spring (March-May), summer (June-August), and fall (September-November). RESULTS: These data represent 2.3 million CDI discharges. Overall, CDI incidence was highest in the Northeast (8.0 CDIs/1,000 discharges) and spring (6.2 CDIs/1,000 discharges). CDI incidence was lowest in the West (4.8 CDIs/1,000 discharges) and fall (5.6 CDIs/1,000 discharges). Peak CDI incidence among children occurred in the West (1.7 CDI/1,000 discharges) and winter (1.5 CDI/1,000 discharges). Mortality among all CDI patients was highest in the Midwest (7.3%) and during the winter (7.9%). CONCLUSION: The region and season with the highest CDI incidence rates among patients hospitalized in U.S. hospitals were the Northeast and spring, respectively. The highest CDI mortality rates were seen in the Midwest and winter. Children exhibited different regional and seasonal CDI variations compared with adults and older adults.