Development and Validation of a Prediction Model for Mortality and Adverse Outcomes among Patients with Peripheral Eosinopenia on Admission for Clostridium difficile Infection

Audrey S. Kulaylat, Erica L. Buonomo, Kenneth W. Scully, Christopher S. Hollenbeak, Heather Cook, William A. Petri, David B. Stewart

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Importance: Recent evidence from an animal model suggests that peripheral loss of eosinophils in Clostridium difficile infection (CDI) is associated with severe disease. The ability to identify high-risk patients with CDI as early as the time of admission could improve outcomes by guiding management decisions. Objective: To construct a model using clinical indices readily available at the time of hospital admission, including peripheral eosinophil counts, to predict inpatient mortality in patients with CDI. Design, Setting, and Participants: In a cohort study, a total of 2065 patients admitted for CDI through the emergency department of 2 tertiary referral centers from January 1, 2005, to December 31, 2015, formed a training and a validation cohort. The sample was stratified by admission eosinophil count (0.0 cells/μL or >0.0 cells/μL), and multivariable logistic regression was used to construct a predictive model for inpatient mortality as well as other disease-related outcomes. Main Outcomes and Measures: Inpatient mortality was the primary outcome. Secondary outcomes included the need for a monitored care setting, need for vasopressors, and rates of inpatient colectomy. Results: Of the 2065 patients in the study, 1092 (52.9%) were women and patients had a mean (SD) age of 63.4 (18.4) years. Those with an undetectable eosinophil count at admission had increased in-hospital mortality in both the training (odds ratio [OR], 2.01; 95% CI, 1.08-3.73; P =.03) and validation (OR, 2.26; 95% CI, 1.33-3.83; P =.002) cohorts in both univariable and multivariable analysis. Undetectable eosinophil counts were also associated with indicators of severe sepsis, such as admission to monitored care settings (OR, 1.40; 95% CI, 1.06-1.86), the need for vasopressors (OR, 2.08; 95% CI, 1.32-3.28), and emergency total colectomy (OR, 2.56; 95% CI, 1.12-5.87). Other significant predictors of mortality at admission included increasing comorbidity burden (for each 1-unit increase: OR, 1.13; 95% CI, 1.05-1.22) and lower systolic blood pressures (for each 1-mm Hg increase: OR, 0.99; 95% CI, 0.98-1.00). In a subgroup analysis of patients presenting without initial tachycardia or hypotension, only patients with undetectable admission eosinophil counts, but not those with an elevated white blood cell count, had significantly increased odds of inpatient mortality (OR, 5.76; 95% CI, 1.99-16.64). Conclusions and Relevance: This study describes a simple, widely available, inexpensive model predicting CDI severity and mortality to identify at-risk patients at the time of admission.

Original languageEnglish (US)
Pages (from-to)1127-1133
Number of pages7
JournalJAMA Surgery
Volume153
Issue number12
DOIs
StatePublished - Dec 2018

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Clostridium Infections
Clostridium difficile
Odds Ratio
Eosinophils
Mortality
Inpatients
Colectomy
Blood Pressure
Hospital Mortality
Leukocyte Count
Tertiary Care Centers
Tachycardia
Hypotension
Hospital Emergency Service
Comorbidity
Sepsis
Emergencies
Cohort Studies
Animal Models
Cell Count

All Science Journal Classification (ASJC) codes

  • Surgery

Cite this

Kulaylat, Audrey S. ; Buonomo, Erica L. ; Scully, Kenneth W. ; Hollenbeak, Christopher S. ; Cook, Heather ; Petri, William A. ; Stewart, David B. / Development and Validation of a Prediction Model for Mortality and Adverse Outcomes among Patients with Peripheral Eosinopenia on Admission for Clostridium difficile Infection. In: JAMA Surgery. 2018 ; Vol. 153, No. 12. pp. 1127-1133.
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title = "Development and Validation of a Prediction Model for Mortality and Adverse Outcomes among Patients with Peripheral Eosinopenia on Admission for Clostridium difficile Infection",
abstract = "Importance: Recent evidence from an animal model suggests that peripheral loss of eosinophils in Clostridium difficile infection (CDI) is associated with severe disease. The ability to identify high-risk patients with CDI as early as the time of admission could improve outcomes by guiding management decisions. Objective: To construct a model using clinical indices readily available at the time of hospital admission, including peripheral eosinophil counts, to predict inpatient mortality in patients with CDI. Design, Setting, and Participants: In a cohort study, a total of 2065 patients admitted for CDI through the emergency department of 2 tertiary referral centers from January 1, 2005, to December 31, 2015, formed a training and a validation cohort. The sample was stratified by admission eosinophil count (0.0 cells/μL or >0.0 cells/μL), and multivariable logistic regression was used to construct a predictive model for inpatient mortality as well as other disease-related outcomes. Main Outcomes and Measures: Inpatient mortality was the primary outcome. Secondary outcomes included the need for a monitored care setting, need for vasopressors, and rates of inpatient colectomy. Results: Of the 2065 patients in the study, 1092 (52.9{\%}) were women and patients had a mean (SD) age of 63.4 (18.4) years. Those with an undetectable eosinophil count at admission had increased in-hospital mortality in both the training (odds ratio [OR], 2.01; 95{\%} CI, 1.08-3.73; P =.03) and validation (OR, 2.26; 95{\%} CI, 1.33-3.83; P =.002) cohorts in both univariable and multivariable analysis. Undetectable eosinophil counts were also associated with indicators of severe sepsis, such as admission to monitored care settings (OR, 1.40; 95{\%} CI, 1.06-1.86), the need for vasopressors (OR, 2.08; 95{\%} CI, 1.32-3.28), and emergency total colectomy (OR, 2.56; 95{\%} CI, 1.12-5.87). Other significant predictors of mortality at admission included increasing comorbidity burden (for each 1-unit increase: OR, 1.13; 95{\%} CI, 1.05-1.22) and lower systolic blood pressures (for each 1-mm Hg increase: OR, 0.99; 95{\%} CI, 0.98-1.00). In a subgroup analysis of patients presenting without initial tachycardia or hypotension, only patients with undetectable admission eosinophil counts, but not those with an elevated white blood cell count, had significantly increased odds of inpatient mortality (OR, 5.76; 95{\%} CI, 1.99-16.64). Conclusions and Relevance: This study describes a simple, widely available, inexpensive model predicting CDI severity and mortality to identify at-risk patients at the time of admission.",
author = "Kulaylat, {Audrey S.} and Buonomo, {Erica L.} and Scully, {Kenneth W.} and Hollenbeak, {Christopher S.} and Heather Cook and Petri, {William A.} and Stewart, {David B.}",
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Development and Validation of a Prediction Model for Mortality and Adverse Outcomes among Patients with Peripheral Eosinopenia on Admission for Clostridium difficile Infection. / Kulaylat, Audrey S.; Buonomo, Erica L.; Scully, Kenneth W.; Hollenbeak, Christopher S.; Cook, Heather; Petri, William A.; Stewart, David B.

In: JAMA Surgery, Vol. 153, No. 12, 12.2018, p. 1127-1133.

Research output: Contribution to journalArticle

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T1 - Development and Validation of a Prediction Model for Mortality and Adverse Outcomes among Patients with Peripheral Eosinopenia on Admission for Clostridium difficile Infection

AU - Kulaylat, Audrey S.

AU - Buonomo, Erica L.

AU - Scully, Kenneth W.

AU - Hollenbeak, Christopher S.

AU - Cook, Heather

AU - Petri, William A.

AU - Stewart, David B.

PY - 2018/12

Y1 - 2018/12

N2 - Importance: Recent evidence from an animal model suggests that peripheral loss of eosinophils in Clostridium difficile infection (CDI) is associated with severe disease. The ability to identify high-risk patients with CDI as early as the time of admission could improve outcomes by guiding management decisions. Objective: To construct a model using clinical indices readily available at the time of hospital admission, including peripheral eosinophil counts, to predict inpatient mortality in patients with CDI. Design, Setting, and Participants: In a cohort study, a total of 2065 patients admitted for CDI through the emergency department of 2 tertiary referral centers from January 1, 2005, to December 31, 2015, formed a training and a validation cohort. The sample was stratified by admission eosinophil count (0.0 cells/μL or >0.0 cells/μL), and multivariable logistic regression was used to construct a predictive model for inpatient mortality as well as other disease-related outcomes. Main Outcomes and Measures: Inpatient mortality was the primary outcome. Secondary outcomes included the need for a monitored care setting, need for vasopressors, and rates of inpatient colectomy. Results: Of the 2065 patients in the study, 1092 (52.9%) were women and patients had a mean (SD) age of 63.4 (18.4) years. Those with an undetectable eosinophil count at admission had increased in-hospital mortality in both the training (odds ratio [OR], 2.01; 95% CI, 1.08-3.73; P =.03) and validation (OR, 2.26; 95% CI, 1.33-3.83; P =.002) cohorts in both univariable and multivariable analysis. Undetectable eosinophil counts were also associated with indicators of severe sepsis, such as admission to monitored care settings (OR, 1.40; 95% CI, 1.06-1.86), the need for vasopressors (OR, 2.08; 95% CI, 1.32-3.28), and emergency total colectomy (OR, 2.56; 95% CI, 1.12-5.87). Other significant predictors of mortality at admission included increasing comorbidity burden (for each 1-unit increase: OR, 1.13; 95% CI, 1.05-1.22) and lower systolic blood pressures (for each 1-mm Hg increase: OR, 0.99; 95% CI, 0.98-1.00). In a subgroup analysis of patients presenting without initial tachycardia or hypotension, only patients with undetectable admission eosinophil counts, but not those with an elevated white blood cell count, had significantly increased odds of inpatient mortality (OR, 5.76; 95% CI, 1.99-16.64). Conclusions and Relevance: This study describes a simple, widely available, inexpensive model predicting CDI severity and mortality to identify at-risk patients at the time of admission.

AB - Importance: Recent evidence from an animal model suggests that peripheral loss of eosinophils in Clostridium difficile infection (CDI) is associated with severe disease. The ability to identify high-risk patients with CDI as early as the time of admission could improve outcomes by guiding management decisions. Objective: To construct a model using clinical indices readily available at the time of hospital admission, including peripheral eosinophil counts, to predict inpatient mortality in patients with CDI. Design, Setting, and Participants: In a cohort study, a total of 2065 patients admitted for CDI through the emergency department of 2 tertiary referral centers from January 1, 2005, to December 31, 2015, formed a training and a validation cohort. The sample was stratified by admission eosinophil count (0.0 cells/μL or >0.0 cells/μL), and multivariable logistic regression was used to construct a predictive model for inpatient mortality as well as other disease-related outcomes. Main Outcomes and Measures: Inpatient mortality was the primary outcome. Secondary outcomes included the need for a monitored care setting, need for vasopressors, and rates of inpatient colectomy. Results: Of the 2065 patients in the study, 1092 (52.9%) were women and patients had a mean (SD) age of 63.4 (18.4) years. Those with an undetectable eosinophil count at admission had increased in-hospital mortality in both the training (odds ratio [OR], 2.01; 95% CI, 1.08-3.73; P =.03) and validation (OR, 2.26; 95% CI, 1.33-3.83; P =.002) cohorts in both univariable and multivariable analysis. Undetectable eosinophil counts were also associated with indicators of severe sepsis, such as admission to monitored care settings (OR, 1.40; 95% CI, 1.06-1.86), the need for vasopressors (OR, 2.08; 95% CI, 1.32-3.28), and emergency total colectomy (OR, 2.56; 95% CI, 1.12-5.87). Other significant predictors of mortality at admission included increasing comorbidity burden (for each 1-unit increase: OR, 1.13; 95% CI, 1.05-1.22) and lower systolic blood pressures (for each 1-mm Hg increase: OR, 0.99; 95% CI, 0.98-1.00). In a subgroup analysis of patients presenting without initial tachycardia or hypotension, only patients with undetectable admission eosinophil counts, but not those with an elevated white blood cell count, had significantly increased odds of inpatient mortality (OR, 5.76; 95% CI, 1.99-16.64). Conclusions and Relevance: This study describes a simple, widely available, inexpensive model predicting CDI severity and mortality to identify at-risk patients at the time of admission.

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