Predicting the risk of Clostridium difficile infection following an outpatient visit: development and external validation of a pragmatic, prognostic risk score

Abstract

Increasing morbidity related to Clostridium difficile infection (CDI) has heightened interest in the identification of patients who would most benefit from recognition of risk and intervention. We sought to develop and validate a prognostic risk score to predict CDI risk for individual patients following an outpatient healthcare visit. We assembled a cohort of Kaiser Permanente Northwest (KPNW) patients with an index outpatient visit between 2005 and 2008, and identified CDI in the year following that visit. Applying Cox regression, we synthesized a priori predictors into a CDI risk score, which we validated among a Kaiser Permanente Colorado (KPCO) cohort. We calculated and plotted the observed 1-year CDI risk for each decile of predicted risk for both cohorts. Among 356 920 KPNW patients, 608 experienced CDI, giving a 1-year incidence of 2.2 CDIs per 1000 patients. The Cox model differentiated between patients who do and do not develop CDI: there was a C-statistic of 0.83 for KPNW. The simpler points-based risk score, derived from the Cox model, was validated successfully among 296 550 KPCO patients, with no decline in the area under the receiver operating characteristic curve: 0.785 (KPNW) vs. 0.790 (KPCO). The predicted risk for CDI agreed closely with the observed risk. Our CDI risk score utilized data collected during usual care to successfully identify patients who developed CDI, discriminating them from patients at the lowest risk for CDI. Our prognostic CDI risk score provides a decision-making tool for clinicians in the outpatient setting.

Prediction of RecurrentClostridium DifficileInfection Using Comprehensive Electronic Medical Records in an Integrated Healthcare Delivery System

“…39,40 Given the major consequences of rCDI on patient outcomes, our results support the need to expand research on the prevention and treatment of recurrence. Such research may also result in the identification of novel predictors that are currently unavailable even in the most comprehensive EMRs.…”

“…Compared to our ability to predict other outcomes (eg, death, unplanned transfer to intensive care), 16 , 20 , 22 our ability to predict rCDI is limited and contrasts with much better ability to predict iCDI 39 40 Given the major consequences of rCDI on patient outcomes, our results support the need to expand research on the prevention and treatment of recurrence.…”

The Antimicrobial Stewardship Approach to Combating Clostridium Difficile

“…ASPs must begin to expand their services within the healthcare system in order to reach patients outside the acute care setting in order to combat non-nosocomially acquired CDAD. A recently developed predictive score can help ASPs identify high risk outpatients and implement targeted interventions [ 88 ]. The need for outpatient ASP interventions targeted at CDAD also encompasses infection control as surveillance estimates that include only inpatient CDAD cases can miss >80% of the total number of cases [ 89 ].…”

Current management of Clostridioides (Clostridium) difficile infection in adults: a summary of recommendations from the 2017 IDSA/SHEA clinical practice guideline

“…In fact, patients with community -associated CDI tend to be older and have more health care exposures than people in the community without CDI. 19,20 Diagnosis CDI is a clinical diagnosis based on the patient's symptoms and risk factors. Testing for C. difficile or toxin production should be targeted at higher -risk patients who have clinically significant diarrhea that is otherwise unexplained.…”