Occurrence of Clostridium Difficile Enterocolitis in Burn Victims Relative to Total Body Surface Area of Injury

Author(s):
Deepak Ozhathil; Caroline Corley; Savannah Skidmore; Heather Evans

Background:

Burn patients are at high risk of infection. Among hospitalized patients Clostridium difficile enterocolitis (CdE) is relatively common due to the routine use of antibiotics and immunomodulation of critical illness. We have observed that CdE occurs at a lower rate than expected in burn victims relative to other at risk population. In order to assess this assertion, we queried a large commercially available multi-center data network to determine if the risk of CdE was influenced by burn injury and how it was affected by total body surface area (TBSA) of burn injury.

Hypothesis:

We believe that burn patients will have a lower risk of CdE than all other at-risk populations and that it will be aggregated by degree of injury.

Methods:

We queried a national data-network across 71 institutions from 2002 to 2022. Patients were divided into cohorts based on the extent of total body surface area (TBSA) injured. CdE was the primary outcome. In additional, the risk of CdE was compared between burn victims and other at-risk populations.

Results:

Cohort size and risk of CdE relative to TBSA injured: <10% (95,127; 0.212%), 10-19% (14,685; 0.429%), 20-29% (4,674; 0.535%), 30-39% (2,271; 1.318%), 40-49% (1,323; 0.756%), 50-59% (884; 1.810%), 60-69% (681;1.468%), 70-79% (516;1.938%), 80-89% (486; 2.058%) and >90% (541; 1.848%). Risk of CdE was increased relative to TBSA injured (slope = 0.0021). Overall risk of CdE for all burn victims was 0.265%. The risk of CdE for all other cohorts: all hospitalized (5,328,190; 0.889%), outpatients & antibiotics (9,327,416; 1.050%), inpatient & antibiotics (3,039,238; 2.659%), immunocompromised (2,431,130; 0.777%), gastric acid suppression (8,143,381; 0.505%) and sepsis (1,209,609; 3.196).  The relative risk of CdE was lower in burn victims than all other at-risk groups, most notably, hospitalized patients (RR = 0.373) and sepsis (RR = 0.087).

Conclusions:

Overall burn trauma appears to incur a lower risk of CdE with risk increased relative to TBSA size. Critical illness and antibiotic exposure are significant risk factors however, this is in sharp contrast with burn victims that are typically septic and receiving broad spectrum antimicrobial suppression. When compared with other relatively lower risk groups, burn injury remains significantly protective against CdE occurrence. Further investigation is required to determine the mechanisms that contribute to these observations.