Assessment of Kidney Injury as a Severity Criteria for Clostridioides Difficile Infection

BACKGROUND: The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) revised their Clostridioides difficile infection (CDI) severity classification criteria in 2017 to include an absolute serum creatinine (SCr) value above a threshold (≥1.5 mg/dL) rather than a relative increase from baseline (≥1.5 times the premorbid level). To date, how to best define kidney injury as a CDI disease severity marker has not been validated to assess severe outcomes associated with CDI. METHODS: This multicenter cohort study included adult hospitalized patients with CDI. Patients were assessed for the presence of acute kidney injury (AKI), chronic kidney disease (CKD), and CDI severity using the 2010 and 2017 IDSA/SHEA CDI guidelines. Primary outcome was all-cause inpatient mortality. RESULTS: The final study cohort consisted of 770 CDI episodes from 705 unique patients aged 65 ± 17 years (female, 54%; CKD, 36.5%; AKI, 29.6%). Eighty-two episodes (10.6%) showed discordant severity classification results due to the inclusion of more patients with preexisting CKD in the severe disease category using an absolute SCr threshold criterion. The absolute SCr criterion better correlated with all-cause mortality (odds ratio [OR], 4.04; 95% confidence interval [CI], 1.76–9.28; P = .001) than the relative increase in SCr (OR, 1.34; 95% CI, 0.62–2.89; P = .46). This corresponded to an increased likelihood of the 2017 CDI severity classification criteria to predict mortality (OR, 5.33; 95% CI, 1.81–15.72; P = .002) compared with the 2010 criteria (OR, 2.71; 95% CI, 1.16–6.32; P = .02). CONCLUSIONS: Our findings support the 2017 IDSA/SHEA CDI severity classification criteria of a single pretreatment SCr in future CDI guideline updates.