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Defining Fulminant Clostridioides difficile Infections: Assessing the Utility of Hypotension as a Diagnostic
Hubert C Chua1, Taryn A Eubank2, Allen Lee3
1Division of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy, Long Island University, Brooklyn, New York, USA.
Insights
Defining hypotension is crucial for identifying severe Clostridioides difficile infection (CDI). This study found that systolic blood pressure ≤90 mm Hg or mean arterial pressure ≤65 mm Hg best predicts poor outcomes in CDI patients.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Clinical Epidemiology
Background:
- Fulminant Clostridioides difficile infection (FCDI) has a high mortality rate (30%-40%).
- Current FCDI severity guidelines include criteria like ileus, megacolon, and shock, but lack a clear definition for hypotension.
- This ambiguity challenges the accurate classification and management of severe CDI cases.
Purpose of the Study:
- To evaluate optimal definitions of hypotension for classifying FCDI severity.
- To determine which hypotension criteria best predict adverse outcomes in patients with CDI.
Main Methods:
- A multicenter cohort study analyzed 1172 hospitalized patients with CDI (Houston cohort) and validated findings in 494 patients (Midwest cohort).
- The study assessed the predictive ability of two hypotension definitions (Systolic Blood Pressure [SBP] ≤90 mm Hg and Mean Arterial Pressure [MAP] ≤65 mm Hg) for a composite endpoint of colectomy or 30-day mortality.
- Multivariable regression models were used to analyze the data.
Main Results:
- The composite endpoint occurred in 8.4% of the Houston cohort and 5.3% of the Midwest cohort.
- Hypotension defined as SBP ≤90 mm Hg or MAP ≤65 mm Hg demonstrated the highest predictive performance for adverse outcomes in both cohorts.
- Excluding hypotension from severity criteria resulted in the poorest predictive model.
Conclusions:
- Incorporating hypotension, defined as SBP ≤90 mm Hg or MAP ≤65 mm Hg, significantly enhances the accuracy of FCDI severity criteria.
- These definitions are vital for identifying CDI patients at higher risk of poor outcomes, including colectomy or mortality.
- Standardizing hypotension definitions improves the clinical utility of FCDI severity assessment.
Background:
Fulminant Clostridioides difficile infection (FCDI) is associated with a 30%-40% mortality rate. Guideline definitions for FCDI severity classification include ileus, megacolon, shock, or hypotension. However, no hypotension definition is provided, making application of the definition challenging. The objective of this study was to assess optimal hypotension definitions for FCDI severity criteria.
Methods:
This was a multicenter cohort study involving 1172 hospitalized patients diagnosed with C difficile infection (CDI) from 2015 to 2022 (Houston cohort). Patients were assessed for a composite endpoint of colectomy or mortality within 30 days of diagnosis. The ability of the CDI severity criteria to predict the composite endpoint was assessed using 2 definitions of hypotension (systolic blood pressure [SBP] ≤90 mm Hg and mean arterial pressure [MAP] ≤65 mm Hg) through multivariable regression models. A separate CDI cohort of 494 hospitalized patients validated the results (Midwest cohort).
Results:
The composite endpoint was similar in the Houston cohort (98 patients [8.4%]) and the Midwest cohort (26 patients [5.3%]). Using either a MAP ≤65 mm Hg or SPB ≤90 mm Hg as criteria for hypotension was the best-performing model in both the development and validation cohorts. Removal of hypotension was the worst-performing model in both cohorts.
Conclusions:
Inclusion of hypotension, defined as SBP ≤90 mm Hg or MAP ≤65 mm Hg, was an important component of FCDI severity criteria, significantly improving the predictive ability to identify FCDI patients at risk for poor outcomes.
