The first case of CDI in Southeast Asia was reported in 1985 [10] and in Thailand in 1990 [12]. incidence of CDI in small populations and over various periods [13-15]. However, the previous data are inhomogeneous and do not represent the overall incidence and burden of CDI in Southeast Asia including Thailand. To address this, we sought to evaluate the incidence, burden, and risk factors for CDI in Thailand by using the nationwide database from 2010. Findings from this study will help to explore the importance of CDI in Thailand, representing Southeast Asia, and help to plan future health policies.
We retrieved in-patient medical data, including the expense of hospitalization, from the 2010 Thailand Nationwide Hospital Admission Database available from the National Health Security Office. The diagnosis of digestive diseases with any form of colitis listed as causes, either as principal diagnosis or comorbidity, coded by the International Classification of Disease and Related Health Problems, 10th Revision (ICD10) was recorded. The inclusion criteria were: (1) diagnosis of enterocolitis because of
Values are expressed as mean ± standard deviation (SD) in normally distributed data. Continuous variables were compared using a Student
Of 4,863,935 admissions in the year 2010, 554 patients in 570 admissions (0.01%) were diagnosed with CDI (ICD10-A07), whereas 214,810 admissions of 204,126 patients (4.4%) were diagnosed with colitis (ICD10-A09). Eighty-eight of the 570 admissions (15.4%) were because of CDI as a principle diagnosis, whereas the remaining cases of CDI were diagnosed later as comorbidity. The highest proportion of CDI cases were found in patients 85 years (40 patients among 7,164 admitted with colitis)
Cases of CDI were equally distributed between men and women (50% each). Of 554 patients with CDI, 493 (89%) had at least one comorbidity, including chronic renal failure, diabetes mellitus, cerebral vascular disease, cardiovascular disease, sepsis, human immunodeficiency virus infection, and/ or inflammatory bowel disease. Of these, sepsis (at 30%) was the most common comorbidity among patients with CDI. In addition, 1.2% of patients with CDI underwent surgery or endoscopy during admission
The proportion of all admissions with colitis in each age-group with Figure 1
Baseline characteristic of patients with colitis and CDI (554 patients in 570 admissions)
Variables | Number (%), n = 570 |
---|---|
Sex; male | 284 (49.8) |
Age (years old) | |
18-44 | 112 (19.6) |
45-64 | 172 (30.2) |
65-84 | 246 (43.2) |
≥85 | 40 (7.0) |
Comorbidity | 508 (89.1) |
Sepsis | 170 (29.8) |
Cerebrovascular disease | 49 (8.6) |
Ischemic heart disease | 46 (8.1) |
End-stage renal disease | 23 (4) |
Inflammatory bowel disease | 7 (1.2) |
Diabetes mellitus | 5 (0.9) |
Human immunodeficiency virus | 3 (0.5) |
Surgery or endoscopy during the index admission | 40 (7) |
Length of hospital stay (mean ± standard deviation) | 32.4 ± 36.7 days |
Twenty-two of 554 patients with CDI (4%) were admitted more than once because of recurrence or relapsed
Multivariate analysis for mortality in CDI patients
Factors | Adjusted OR (95%C1) | |
---|---|---|
Age ≥85 years old | 2.40 (1.09,5.27) | 0.03 |
Length of hospital stay | 1.00 (0.99,1.00) | 0.86 |
Per additional comorbidity | 7.47 (1.78,31.36) | 0.006 |
Sepsis | 5.41 (3.40,8.62) | <0.001 |
Surgery or endoscopy | 0.28 (0.08,0.98) | 0.04 |
OR, odds ratio; CI, confidence interval.
There are many reasons why the incidence of CDI may differ regionally. Diet is known as an important factor causing modification of gut microbiota, and a normal flora may be associated with CDI [21]. Consequently, Asian populations may have different microbiota than populations in Western countries and this may account for the lower rate of CDI in Thai and Korean people. A study in China [22] found that Chinese
This study emphasized that old age is an important factor for CDI infection and can predict mortality because of CDI. Although much of the CDI occurred in young to middle-age patients (i.e., <65 years old), the proportion varied within each age group. The highest incidence for CDI was found in the group ≥85 years-old, whereas the proportions in the 18-44, 45-64, and 65-84 year-old age groups were progressively less with age
Comorbidity is an important parameter in the mortality rate of CDI patients. Approximately 90% of CDI patients had comorbidity, and almost all of the patients who died during index admission had comorbidity (98.1%). Comorbidity has been suggested as the precipitating factor of CDI, but the evidence has not been clear [7]. Here we show that comorbidity is an important mortality risk factor with an OR of 7.47 in multivariate analysis. In this study, the most important comorbidity associated with mortality was sepsis. Sepsis is a risk factor that predicts CDI because patients always require antibiotic treatment, which is a well-known risk factor for CDI [7, 23]. LOS was not a predictor of death, because severe CDI was life-threatening, and these patients typically died within a few days after diagnosis.
Our retrospectively data collection is the main limitation of the present study. The authors obtained all information from summary discharge; therefore, the information was limited. This study could not retrieve the result of investigation, criteria for CDI diagnosis, history of antibiotic usage, history of previous admission from other causes, nor other possible associated risk factors, such as proton pump inhibitor prescription. Moreover, this study relied on ICD 10 coding for CDI diagnosis, which may be inaccurate. Nevertheless, this is the first large scale study in Thailand that can represent the actual situation and can thus guide future health policy decisions.
From a first nationwide study in Thailand, the burden of CDI infection in Thailand is high, even though the prevalence of CDI is likely to be relatively low. National health policies should improve strategies to prevent CDI.