10 YEARS OF PROSPECTIVE CLOSTRIDIUM-DIFFICILE-ASSOCIATED DISEASE SURVEILLANCE AND TREATMENT AT THE MINNEAPOLIS-VA-MEDICAL-CENTER, 1982-1991

OBJECTIVES: To understand the epidemiology, risks, and management of C lostridium difficile-associated disease (CDAD) and to establish and ev aluate reliable methods of surveillance. DESIGN: Case finding was done by daily ward and laboratory rounds. The criteria for CDAD diagnosis were: at least four unformed stools per day for 2 days and a positive culture or cytotoxin for C difficile, or positive endoscopy or autopsy for pseudomembranes. SETTING: The surveillance covered all patients f rom 1982 through 1991 in the 820-bed Minneapolis Veterans Affairs Medi cal Center. PARTICIPANTS: The criteria were met by 908 patients. Medic al service patients numbered 488; surgical patients, 420. Frequencies ranged from a high of 149 cases in 1982 to a low of 50 cases in 1989. RESULTS: Stool specimens were obtained on 898 (99%) of the 908 CDAD pa tients. Stools were culture-positive in 864 (96%) of 898, cytotoxin-po sitive in 569 (63%) of 898. Endoscopy was performed on 196 (22%) of th e 908 patients, and 80 (41%) of 196 patients had pseudomembranes. Ten (1%) of the 908 patients were diagnosed by endoscopy without a stool s pecimen, or at autopsy. No treatment was needed for 135 (15%) of the 9 08 CDAD patients, and 19 (2%) of the 908 died before treatment was sta rted. Oral metronidazole was the treatment for 632 (70%) of 908 patien ts (1% intolerance, 2% failure, 7% relapse) and oral vancomycin was gi ven to 122 (13%) of 908 patients (1% intolerance, 1% failure, 10% rela pse). Twelve patients had pseudomembranous colitis at autopsy, and it was the primary cause of death in 5 (0.6%) of 908. CONCLUSIONS: CDAD u sually responds to oral metronidazole or vancomycin but is nonetheless responsible for a high morbidity and occasional mortality in patients even when the diagnosis and treatment are pursued aggressively (Infec t Control Hosp Epidemiol 1994; 15:371-381).