title: Epidemiology and outcomes of clostridium difficile-associated disease among patients on prolonged acute mechanical ventilation.
abstract: OBJECTIVE
  Patients receiving prolonged acute mechanical ventilation (PAMV), although comprising a third of all mechanical ventilation (MV) patients, consume two-thirds of all the resources allocated to MV, and their numbers are projected to double by 2020. By virtue of their prolonged hospital length of stay (median LOS, 17 days), they are subject to such nosocomial infections as Clostridium difficile-associated disease (CDAD), the incidence and age-adjusted case fatality rate of which doubled between 2000 and 2005. We examined the rates and outcomes of CDAD among adult PAMV patients.
  
  
  METHODS
  We analyzed 2005 data from the Health Care Utilization Project/Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. PAMV and CDAD were identified using the International Classification of Diseases, ninth revision, clinical modification codes 96.72 and 008.45, respectively.
  
  
  RESULTS
  Among 64,910 adult PAMV patients who were discharged in 2005, 3,468 patients (5.34%) had a concurrent diagnosis of CDAD (PAMV patients who were discharged with concomitant diagnosis of CDAD [CDAD+]). CDAD+ patients who were discharged were older (mean [+/- SD] age, 66.7 +/- 15.9 vs 63.7 +/- 16.9 years, respectively; p < 0.001) and were more likely to have been admitted to the hospital from a long-term care facility (5.7% vs 2.9%, respectively; p < 0.001) than PAMV patients who were discharged without CDAD (CDAD-). Although crude hospital mortality rates did not differ among PAMV patients who were discharged from the hospital by CDAD status (CDAD+, 32.6%; CDAD-, 33.0%; p = 0.598), both unadjusted calculations and propensity-score adjustment showed a substantial increase in LOS (6.1 days; 95% confidence interval [CI], 4.9 to 7.4) and total costs ($10,355; 95% CI, $7,540 to $13,170) among CDAD+ patients.
  
  
  CONCLUSIONS
  PAMV patients have an order of magnitude higher risk of having CDAD than other hospitalized patients. Concurrent CDAD infection is associated with increased hospital LOS and costs. The PAMV population is an attractive target for aggressive measures aimed at CDAD prevention.
authors.affiliation: School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA; EviMed Research Group, LLC, Goshen, MA. Electronic address: Marya@evimedgroup.org.
authors.forename: Marya D
authors.initials: MD
authors.lastname: Zilberberg
authors.affiliation: OptiStatim, LLC, Longmeadow, MA.
authors.forename: Brian H
authors.initials: BH
authors.lastname: Nathanson
authors.affiliation: School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA.
authors.forename: Shamil
authors.initials: S
authors.lastname: Sadigov
authors.affiliation: Baystate Medical Center, Springfield, MA.
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Higgins
authors.affiliation: Washington University School of Medicine, St. Louis, MO.
authors.forename: Marin H
authors.initials: MH
authors.lastname: Kollef
authors.affiliation: Washington Hospital Center, Washington, DC.
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Shorr
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D016360:Clostridioides difficile; D003015:Clostridium Infections / Q000191:economics / Q000453:epidemiology*; D003428:Cross Infection / Q000191:economics / Q000453:epidemiology*; D005260:Female; D017721:Hospital Costs; D006801:Humans; D015994:Incidence; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D012372:ROC Curve; D012121:Respiration, Artificial / Q000009:adverse effects* / Q000191:economics; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology