| Abstract | UVOD: Važnost infekcija uzrokovanih bakterijom Clostridium difficile u stalnom je porastu. Dosadašnje se smjernice liječenja temelje na broju epizode Clostridium difficile infekcije (CDI) i na procjeni kliničke težine bolesti. Pridržavanje smjernica pri liječenju naših bolesnika do sada nije ispitivano. Također, rezultati novijih studija osporavaju opravdanost inicijalne primjene metronidazola p.o. u liječenju prvih, klinički blagih i srednje teških epizoda bolesti. ----- CILJ: Utvrditi primijenjenu inicijalnu terapiju za liječenje CDI i usporediti je s postojećim preporukama liječenja prema kliničkoj težini bolesti i broju epizode CDI te usporediti ishode liječenja prve epizode CDI s obzirom na vrstu primijenjene inicijalne terapije i kliničku težinu bolesti. ----- BOLESNICI I METODE: Radi se o retrospektivnome deskriptivnom istraživanju provedenom na bolesnicima oba spola i svih dobi hospitalno liječenim zbog dijareje uzrokovane laboratorijski potvrđenom CDI u razdoblju od 2013. do 2017. godine u Klinici za infektivne bolesti "Dr. Fran Mihaljević" u Zagrebu. ----- REZULTATI: 705/1073 (65,7%) bolesnika s CDI liječeno je prema preporukama, a njihov se udio značajno razlikovao s obzirom na epizodu bolesti (prva: 56,3%, druga: 81,8%, ≥ treća epizoda: 85,6%; p < 0,0001). Unutar skupina bolesnika po broju epizode utvrđena je značajna razlika u udjelu liječenih prema preporukama s obzirom na kliničku težinu bolesti (p < 0,0001), s najmanjim udjelom u skupinama bolesnika s teškom kompliciranom bolesti (21,6% kod prve, 15,4% kod druge i 25% kod ≥ treće epizode). Među 695 bolesnika liječenih zbog prve epizode CDI, stratificiranih po težini bolesti, vankomicin p.o. je u odnosu na metronidazol p.o. postigao povoljan klinički učinak u značajno većem udjelu u tri od četiri skupine bolesnika: u skupini s blagom (100 vs. 72,1%), srednje teškom (96,6 vs. 79,1%) i teškom bolesti (86,7 vs. 66,7%). Dužina liječenja nakon postavljanja dijagnoze CDI s obzirom na primijenjenu inicijalnu terapiju značajno se razlikovala samo u podskupini s blagom bolesti (vankomicin 14,2 dana vs. metronidazol 9,6 dana; p = 0,0150). Nije utvrđena statistički značajna razlika ni u udjelu liječenih u jedinici intenzivne medicine (JIM) ni u bolničkom preživljenju s obzirom na kliničku težinu bolesti i primijenjenu inicijalnu terapiju. ----- ZAKLJUČAK: Udio bolesnika s CDI liječenih prema preporukama bio je manji od očekivanog, ali veći u odnosu na rezultate dosadašnjih studija, a rezultati ukazuju na nepoštivanje kriterija težine bolesti pri odlučivanju o liječenju, naročito u slučaju teških i teških kompliciranih CDI. Značajno povoljniji klinički učinak zabilježen u bolesnika s klinički blagom i srednje teškom prvom epizodom bolesti liječenih vankomicinom p.o. upućuje na opravdanost preporuke primjene vankomicina p.o. i u tim podskupinama bolesnika. |
| Abstract (english) | BACKGROUND: The importance of Clostridium difficile infection (CDI) is on the rise. Current treatment guidelines are based on determining the CDI episode number and estimating the disease severity. Adherence to guidelines in CDI treatment at our clinic has not been investigated before. The results of recent studies have questioned the validity of recommending metronidazole PO as initial treatment of the first mild/moderate CDI. ----- OBJECTIVE: To determine the administered primary therapy for CDI and compare it to the current treatment guidelines according to the disease severity and CDI episode number and to compare treatment outcomes of the first CDI episode based on the administered primary therapy and disease severity. ----- PATIENTS AND METHODS: This was a retrospective descriptive study which included patients of all age groups and both genders with laboratory-detected infection hospitalized and treated for CDI at University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, from 2013 to 2017. ----- RESULTS: 705/1073 (65.7%) of patients with CDI were appropriately treated according to guidelines, and adherence to guidelines differed significantly based on the CDI episode number (the first 56.3%, the second 81.8%, the ≥ third episode 85.6%; p < 0,0001). In each of the aforementioned groups of patients there was a significant difference in adherence to guidelines based on the disease severity (p < 0.0001), with the lowest results in the severe-complicated CDI group (21.6% for the first, 15.4% for the second i 25.0% for the ≥ third episode). In 695 patients treated for the first CDI episode and stratified by disease severity favorable treatment response to vancomycin PO was significantly more common than that to metronidazole PO in three of four groups of patients: mild (100 vs. 72.1%), moderate (96.6 vs. 79.1%), and severe CDI (86.7 vs. 66.7%). Based on the initial treatment, difference in length of hospital stay after CDI diagnosis was statistically significant only in the mild CDI group (vancomycin 14.2 days vs. metronidazole 9,6 days; p = 0,0150). There was no statistically significant difference in the number of patients treated in the intensive care unit (ICU) nor in the hospital survival rates based on the disease severity and administered primary therapy. ----- CONCLUSIONS: Adherence to guidelines in CDI treatment was lower than expected, but higher than the results recorded in other studies. Our results point to the physicians' disregard for the disease severity criteria when deciding on initial treatment, especially in severe and severe-complicated CDI. Significantly higher favorable treatment response rate recorded in patients with mild and moderate CDI treated with vancomycin PO justifies the recommendation of vancomycin PO as initial treatment in those groups. |
