Background: The overall incidence of Clostridium difficile infection (CDI) is higher among patients with inflammatory bowel disease (IBD). The nature of this disease association is unknown but likely involves an altered gut microbiome and impaired host immune responses. Studies on CDI in IBD patients have yielded variable and conflicting results on outcome measures such as colectomy rates, hospitalization burden, and mortality. Nonetheless, there is still reasonable concern that CDI leads to increased morbidity, healthcare costs, and mortality in patients with IBD. Current guidelines from the American College of Gastroenterology recommend testing for Clostridium difficile in patients admitted to the hospital with IBD who have diarrhea. The purpose of this study is to determine the rate at which this occurs and to implement quality improvement (QI) interventions in an effort to improve this rate.
Methods: This was a retrospective, cross-sectional study. We used ICD-9 and ICD-10 discharge diagnosis codes to obtain a list of patients with IBD admitted to the hospital during 2014. Inclusion criteria were age greater than 18, a history of inflammatory bowel disease that was either documented by a gastroenterology specialist or confirmed by endoscopic and/or pathologic findings, and the presence of diarrhea on admission (bloody or non-bloody). Patients without a documented and/or confirmed diagnosis of inflammatory bowel disease were excluded from this study. Outpatients, patients without diarrhea, and patients admitted prior to and after 2014 were also excluded. Patient data was collected in a de-identified manner from the electronic medical record (EMR) and was recorded in a secure Microsoft Excel spreadsheet. Specific patient data collected included age, gender, symptoms, Clostridium difficile stool testing, immunosuppression therapy on presentation, temperature, white blood cell count, albumin level, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level. Data interpretation and statistical analysis was performed by study investigators. From a standpoint of quality improvement, we developed hospital-based measures to improve the rate at which IBD patients are tested for CDI. These included implementing reminders in electronic medical record (EMR), and educational resources to increase awareness, including flyers, noon conferences and posters.
Results: A total of 36 patients were included. There was a fairly even distribution in both gender and disease type. A total of 9 (25%) patients had no Clostridium difficile testing performed. A total of 5 (13.8%) patients were found to have a positive test, and 22 (61.1%) patients had a negative test. In addition, hypoalbuminemia, which has not traditionally been used to assess disease severity in patients with IBD, was found in 55.5% of patients.
Conclusions: This study indicated that in our hospital setting testing for Clostridium difficile infection in patients with Inflammatory Bowel Disease (IBD) can be improved. These findings can be extrapolated and incorporated into the quality improvement protocols of larger settings. Additionally, a relatively high number of patients found to have hypoalbuminemia on presentation suggests it’s potential use in assessing disease control and severity.