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A Severity of C. difficile-Associated Disease (CDAD) Index Predicts Treatment Outcomes with Metronidazole

Belmares J, Parada JP, Miskevics SA, Weaver FM, Gerding DN, Johnson SB. A Severity of C. difficile-Associated Disease (CDAD) Index Predicts Treatment Outcomes with Metronidazole. Paper presented at: Infectious Diseases Society of America Annual Meeting; 2006 Oct 13; Toronto, Canada.


Background: CDAD frequency and severity are increasing while the effectiveness of initial therapy with metronidazole (MTR) has been questioned. There is no standardized instrument to assess CDAD severity or measure treatment outcomes with MTR. Methods: We conducted a retrospective review of inpatients with CDAD (positive C. difficile toxin and documented diarrhea) from 1/2003-9/2004. Primary outcome was diarrhea resolution within 6 days of MTR treatment. Documented Successes (DS) had documentation of diarrhea resolution. Probable Cures (PC) had improvement but were discharged before full symptom resolution. Treatment failures had continued diarrhea after 6 days of MTR and were further classified as Slow Responders (SR) who resolved their symptoms after 6 days without changes of therapy, or True Failures (TrF) who required treatment other than MTR to resolve the diarrhea. CDAD severity score (CDADSS) was calculated by adding 1 point for each of the following: fever (T > 38°C), ileus, SBP < 100mmHg, WBC ≥ 15,000/mm3 (2 points if WBC ≥ 30,000/mm3). One CT finding* added 1 point, ≥ 2 findings added 2 points. (*CT findings: thickened colonic wall, ascites, or colonic dilatation.) Results: 102 cases (97% male, age 36-87) were reviewed. 57.8 % were DS, 14.7% were PC, 19.6% were SR for a total of 94 (92.1%) response to MTR. Mean CDADSS in MTR responders (DS + PC + SR) vs. TrF were 0.76 and 2.87, respectively. (p < 0.0001) Conclusions: CDAD response to MTR was > 90%, although 20% of these responses were SR. CDADSS was significantly higher in true failures of CDAD treatment with MTR, suggesting potential utility for predicting treatment outcomes. Further work is needed to refine this index and validate it prospectively.

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