Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003:: a changing pattern of disease severity
Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003:: a changing pattern of disease severity
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DOI：
10.1503/cmaj.1041104
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发表时间：
2004-08-31
影响因子：
14.6
通讯作者：
Chouinard, D
中科院分区：
文献类型：
--
作者：
Pépin, J;Valiquette, L;Chouinard, D
背景：最近的报道表明艰难梭菌结肠炎可能正在演变成一种更严重的疾病。在2002年下半年，我们注意到我们机构中患有严重艰难梭菌相关性腹泻（CDAD）的患者数量有所增加。我们描述了我们机构13年来的CDAD病例，并调查了疾病严重程度的变化。方法：我们对1991年1月1日至2003年12月31日在舍布鲁克大学医院中心诊断的所有CDAD病例进行回顾性分析。由于该医院服务于魁北克省明确的人群，我们也能够在此期间计算基于人群的发病率。我们从患者图表以及医院和药房的计算机数据库中提取了个别患者的数据。我们将CDAD病例定义为艰难梭菌细胞毒性检测结果阳性，或内窥镜或组织病理学证据为假膜性结肠炎。如果观察到以下一种或多种情况：巨结肠、穿孔、结肠切除术、需要血管加压治疗的休克或诊断后30天内死亡，则认为病例是复杂的。结果：研究期间共诊断出1721例CDAD。发病率从1991年的每10万人35.6人上升到2003年的每10万人156.3人；在65岁及以上的患者中，从每10万人102.0例增加到866.5例。合并病例比例从1991-1992年的7.1%（12/169）上升到2003年的18.2% (71/390)(p < 0.001)，诊断后30 d内死亡比例从1991-1992年的4.7%（8/169）上升到2003年的13.8% (54/390)（p < 0.001）。白细胞计数高（20.0 × 10(9)/L或更高）和肌酐水平升高（200mumol /L或更高）与不良结局密切相关：2003年，110例白细胞计数或肌酐水平高或两者均高的患者中有45例（40.9%）合并CDAD， 28例（25.5%）在诊断后30天内死亡。在调整年龄和其他混杂因素后，最初接受口服万古霉素治疗的患者进展为复杂CDAD的风险比最初接受甲硝唑治疗的患者低79%（校正优势比为0.2,95%可信区间为0.06-0.8,p = 0.02）。解释：随着病死率的增加，CDAD的流行对我们地区的老年人口产生了重要影响。我们的观察数据表明，万古霉素和甲硝唑治疗CDAD的等效性需要质疑。
Background: Recent reports suggest that Clostridium difficile colitis may be evolving into a more severe disease. During the second half of 2002 we noted an increase in the number of patients with severe C. difficile-associated diarrhea (CDAD) in our institution. We describe cases of CDAD at our institution over a 13-year period and investigate changes in illness severity.Methods: We undertook a retrospective chart review of all cases of CDAD diagnosed at the Centre hospitalier universitaire de Sherbrooke from Jan. 1, 1991, to Dec. 31, 2003. Because the hospital serves a well-defined population of Quebec, we were also able to calculate population-based incidence during this period. We abstracted data on individual patients from patient charts and from hospital and pharmacy computer databases. We defined cases of CDAD as having a positive C. difficile cytotoxicity assay result, or endoscopic or histopathological evidence of pseudomembranous colitis. A case was considered complicated if one or more of the following was observed: megacolon, perforation, colectomy, shock requiring vasopressor therapy, or death within 30 days after diagnosis.Results: A total of 1721 cases of CDAD were diagnosed during the study period. The incidence increased from 35.6 per 100 000 population in 1991 to 156.3 per 100 000 in 2003; among patients aged 65 years or more, it increased from 102.0 to 866.5 per 100 000. The proportion of cases that were complicated increased from 7.1% (12/169) in 1991-1992 to 18.2% (71/390) in 2003 (p < 0.001), and the proportion of patients who died within 30 days after diagnosis increased from 4.7% (8/169) in 1991-1992 to 13.8% (54/390) in 2003 (p < 0.001). A high leukocyte count (20.0 x 10(9)/L or greater) and an elevated creatinine level (200 mumol/L or greater) were strongly associated with adverse outcomes: in 2003, 45 (40.9%) of 110 patients with a high leukocyte count or creatinine level, or both, had complicated CDAD and 28 (25.5%) died within 30 days after diagnosis. After adjustment for age and other confounding factors, patients initially given oral vancomycin therapy had a risk of progression to complicated CDAD that was 79% lower than the risk among patients-initially treated with metronidazole (adjusted odds ratio 0.2, 95% confidence interval 0.06-0.8, p = 0.02).Interpretation: An epidemic of CDAD with an increased case-fatality rate has had important consequences on the elderly population of our region. Our observational data suggest that the equivalence of vancomycin and metronidazole in the treatment of CDAD needs to be questioned.