BACKGROUND: Clostridium difficile infections (CDI) are the leading cause of gastroenteritis-associated death and result in significant financial burden on the healthcare system. Due to the difficulty in determining the role of CDI in the death of patients with multiple comorbidities, CDI may be under-recognized as a contributing cause of death. We described deaths among Minnesota (MN) CDI patients during 2009–2013 to identify potential risk factors.
METHODS: The MN Department of Health performs active population- and laboratory-based surveillance for CDI in 5 counties as part of the CDC’s Emerging Infections Program. A CDI case was defined as a positive C. difficile toxin or molecular assay on a stool specimen from a person without a prior positive assay in the past 8 weeks. Additional medical record review was performed on CDI cases who died within 6 months of a positive test. Data on CDI signs and symptoms, treatment for CDI at the time of death, and listed causes of death on final discharge diagnoses and death certificates were collected. Healthcare exposures, Charlson comorbidity score, prior medications, and treatment at the time of CDI diagnosis were compared between CDI cases who died versus those who survived.
RESULTS: Of 1,944 CDI cases identified during 2009–2013, 189 (10%) died within 6 months of a positive C. difficile test. Of the CDI case deaths, 94 (50%) died within 30 days of a positive test, 83 (44%) had active diarrhea, 96 (51%) were being treated for CDI, and 26 (13%) had CDI listed as a cause of death on their death certificates. Of the 129 cases with a final discharge diagnosis documented within 7 days of death, CDI was listed in 63 (49%) of case medical records. Cases who died had higher average Charlson comorbidity score (7 vs. 3, p<0.001) and were significantly more likely to have overnight healthcare exposure in the 12 weeks prior to positive stool collection (65% vs. 30%, p<0.001) and be prescribed antimicrobial therapy (72% vs. 59%, p=0.001) in the 12 weeks prior to positive stool collection compared to surviving CDI cases.
CONCLUSIONS: Based on timing and ongoing disease symptoms or treatment, death certificates under-reported CDI as a contributing cause of death and thus underestimated associated mortality. Clinicians are encouraged to list CDI as a contributing cause of death when appropriate. Currently, death certificates do not appear to accurately report the impact and contribution of CDI.