Does Obesity Influence the Risk of Clostridium difficile Infection Among Patients with Ulcerative Colitis?

A Systematic Literature Review on Risk Factors for and Timing of Clostridioides difficile Infection in the United States

INTRODUCTION

Clostridioides difficile infection (CDI) is a major public health threat. Up to 40% of patients with CDI experience recurrent CDI (rCDI), which is associated with increased morbidity. This study aimed to define an at-risk population by obtaining a detailed understanding of the different factors leading to CDI, rCDI, and CDI-related morbidity and of time to CDI.

METHODS

We conducted a systematic literature review (SLR) of MEDLINE (using PubMed) and EMBASE for relevant articles published between January 1, 2016, and November 11, 2022, covering the US population.

RESULTS

Of the 1324 articles identified, 151 met prespecified inclusion criteria. Advanced patient age was a likely risk factor for primary CDI within a general population, with significant risk estimates identified in nine of 10 studies. Older age was less important in specific populations with comorbidities usually diagnosed at earlier age, such as bowel disease and cancer. In terms of comorbidities, the established factors of infection, kidney disease, liver disease, cardiovascular disease, and bowel disease along with several new factors (including anemia, fluid and electrolyte disorders, and coagulation disorders) were likely risk factors for primary CDI. Data on diabetes, cancer, and obesity were mixed. Other primary CDI risk factors were antibiotics, proton pump inhibitors, female sex, prior hospitalization, and the length of stay in hospital. Similar factors were identified for rCDI, but evidence was limited. Older age was a likely risk factor for mortality. Timing of primary CDI varied depending on the population: 2-3 weeks in patients receiving stem cell transplants, within 3 weeks for patients undergoing surgery, and generally more than 3 weeks following solid organ transplant.

CONCLUSION

This SLR uses recent evidence to define the most important factors associated with CDI, confirming those that are well established and highlighting new ones that could help to identify patient populations at high risk.

Risk factors for clostridium difficile infection in general surgery patients

BACKGROUND

Clostridium Difficile Infection (CDI) is a significant cause of mortality. This study aims to identify predictors of CDI in general surgery patients.

METHODS

Patients who underwent general surgery operations in the 2019 National Surgical Quality Improvement Program database were identified with demographic, intervention, and outcome data abstracted. Patients with CDI and no CDI were compared by univariate analysis. Multivariable logistic regression (MLR) was performed to determine independent predictors of CDI.

RESULTS

Of 436,831 surgical patients, 1,840 patients were diagnosed with CDI (0.4%). Patients with CDI have a higher mortality (2.1% vs 0.76%,p < 0.0001), longer length of stay (7 days vs 1 day, p < 0.0001), and are less likely to undergo a laparoscopic procedure (29.9% vs 37.5%, p < 0.0001). MLR identified older age, emergent operation, increased time to operation, surgical site infection, deep organ space infection, steroid use, metastatic cancer, smoking, and decreased body mass index (BMI) as independent predictors of CDI.

CONCLUSIONS

CDI is rare following general surgery. Infections, delay to operation, and emergency operations are associated with CDI.

Long-term Outcomes Following Multiply Recurrent Clostridioides difficile Infection and Fecal Microbiota Transplantation

BACKGROUND AND AIMS

Fecal microbiota transplantation (FMT) is a commonly used therapy for multiply recurrent Clostridioides difficile (mrCDI). By altering the gut microbiota, there is the potential for FMT to impact the risk for cardiometabolic, intestinal or immune-mediated conditions. Likewise, the microbiota disturbance associated with mrCDI could potentially lead to these conditions. We aimed to assess the associations of mrCDI and FMT with cardiometabolic, immune-mediated diseases, and irritable bowel syndrome.

METHODS

This retrospective cohort study using a United States commercial claims database included persons diagnosed with CDI or undergoing FMT. We created 2 pairwise comparisons: mrCDI vs non-mrCDI, and non-mrCDI or mrCDI treated with FMT vs mrCDI without FMT.

RESULTS

We found no significant association between mrCDI (vs non-mrCDI) and inflammatory bowel disease (adjusted hazard ratio (aHR) = 1.65; 95% confidence interval, 0.67-4.04), rheumatoid arthritis (HR = 0.86; 0.47-1.56), psoriasis (HR = 0.72; 0.23-2.27), diabetes (aHR = 0.97; 0.67-1.40), hypertension (aHR = 1.05; 0.76-1.44), myocardial infarction (aHR = 0.82; 0.63-1.06), stroke (aHR = 0.83; 0.62-1.12), or irritable bowel syndrome (HR = 0.94; 0.61-1.45). Similarly, we found no association of CDI with FMT (vs mrCDI without FMT) and diabetes (aHR = 0.92; 0.27-3.11), hypertension (aHR = 1.41; 0.64-3.15), stroke (aHR = 1.27; 0.69-2.34) or inflammatory bowel syndrome (aHR = 0.80; 0.26-2.46). However, the incidence of myocardial infarction was increased following FMT (aHR = 1.68; 1.01-2.81).

CONCLUSION

Relative to those with CDI, persons with mrCDI do not appear to be intrinsically at higher risk of cardiometabolic, immune-mediated diseases, or irritable bowel syndrome. However, those who underwent FMT for CDI had a higher incidence of myocardial infarction. Future studies should assess this association to assess reproducibility.

Body mass index and risk of clostridioides difficile infection: a systematic review and meta-analysis

OBJECTIVE

To comprehensively investigate the association between obesity/high body mass index (BMI) and risk of Clostridioides difficile infection (CDI) using systematic review and meta-analysis.

METHODS

Potentially eligible studies were identified from Medline and EMBASE databases from inception to February 2021 using search strategy consisting of terms for "Body Mass Index" and "Clostridioides Difficile". We only included studies that consist of a group of individuals with CDI and another group without CDI. Then, the studies must report their BMI or history of obesity. Odds ratio (OR) and 95% CIs of the association between BMI status and CDI were retrieved from each study and combined using the generic inverse variance method. Funnel plot was used to assess publication bias.

RESULTS

A total of 4609 articles were identified. After two rounds of systematic review, 17 studies met the eligibility criteria and were included into the meta-analysis. Pooled analysis showed that individuals with high BMI had a significantly decreased odds of CDI with the pooled OR of 0.88 (95% CI 0.80-0.97). This meta-analysis had high statistical heterogeneity with I² of 74%. Funnel plot was symmetric, which was not suggestive of presence of publication bias.

CONCLUSION

This meta-analysis revealed a significant negative association between BMI and CDI.

Nonalcoholic Fatty Liver Disease-A Novel Risk Factor for Recurrent Clostridioides difficile Infection

Recurrent Clostridioides difficile infections (rCDI) have a substantial impact on healthcare systems, with limited and often expensive therapeutic options. Nonalcoholic fatty liver disease (NAFLD) affects about 25% of the adult population and is associated with metabolic syndrome, changes in gut microbiome and bile acids biosynthesis, all possibly related with rCDI. The aim of this study was to determine whether NAFLD is a risk factor associated with rCDI. A retrospective cohort study included patients ≥ 60 years hospitalized with CDI. The cohort was divided into two groups: those who were and were not readmitted with CDI within 3 months of discharge. Of the 329 patients included, 107 patients (32.5%) experienced rCDI. Patients with rCDI were older, had higher Charlson Age-Comorbidity Index (CACI) and were more frequently hospitalized within 3 months. Except for chronic kidney disease and NAFLD, which were more frequent in the rCDI group, there were no differences in other comorbidities, antibiotic classes used and duration of antimicrobial therapy. Multivariable Cox regression analysis showed that age >75 years, NAFLD, CACI >6, chronic kidney disease, statins and immobility were associated with rCDI. In conclusion, our study identified NAFLD as a possible new host-related risk factor associated with rCDI.

Immunosuppression and Clostridioides (Clostridium) difficile Infection Risk in Metabolic and Bariatric Surgery Patients

BACKGROUND

Immunosuppressant use increases risk of Clostridioides (Clostridium) difficile infection. To date, no studies have analyzed the relationship between immunosuppressant use and C difficile infections after metabolic and bariatric surgery (MBS).

METHODS

A retrospective analysis of the 2015-2018 MBSAQIP data was conducted. The MBSAQIP data include information from 854 affiliated practices in the US and Canada. Initial sample size was 760,076 MBS patients. After excluding participants due to missing variables (n = 188,106) and the use of surgical procedures other than Roux-en-Y gastric bypass and sleeve gastroplasty (n = 129,712), final analyses were performed on 442,258 participants. Logistic regression models generated the odds of C difficile infection developing post MBS, according to immunosuppressant status (positive or negative).

RESULTS

Unadjusted logistic regression analysis showed that patients using immunosuppressants were 95% more likely to have postoperative C difficile infection (odds ratio 1.945; 95% CI, 1.230 to 3.075; p < 0.001) vs MBS patients not taking immunosuppressants. After adjusting for age, sex, ethnicity, preoperative BMI, diabetes status, and surgical procedure type, the association remained unaffected (adjusted odds ratio 1.956; 95% CI, 1.236 to 3.095; p < 0.01). Patients who completed the laparoscopic Roux-en-Y gastric bypass procedure had more than double the odds of C difficile infection developing compared with those who completed the laparoscopic sleeve gastrectomy procedure (odds ratio 2.183; 95% CI, 1.842 to 2.587; p < 0.0001).

CONCLUSIONS

Our results using a population-based sample of MBS patients showed that those taking immunosuppressants have a significantly higher risk of developing Clostridioides (Clostridium) difficile infection postoperatively. These findings suggest that patients using immunosuppressants should be closely monitored both pre and post procedure.

Novel risk factors and outcomes in inflammatory bowel disease patients with Clostridioides difficile infection

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at significantly increased risk for Clostridioides difficile infection (CDI) with an increased risk of adverse outcomes including increased in-hospital mortality, IBD treatment failure, re-hospitalization, and high CDI recurrence rates. The existing literature on predictors of these adverse outcomes is limited. We evaluated four potentially modifiable novel risk factors [body mass index (BMI), statin use, opioid use, and antidepressant use] on CDI risk and adverse outcomes in these patients.

METHODS

Using a retrospective design, variables were abstracted from records for patients with IBD and CDI from 2008 to 2013. Statistical analysis comprised descriptive statistics and univariate and multivariate logistic regression analyses.

RESULTS

There were 137 patients with IBD and CDI included in this study. On multivariate analysis controlling for age, 43% of patients in the overweight BMI category had severe or severe, complicated CDI, compared with 22% of patients in the underweight/normal BMI [odds ratio (OR) 2.85, p = 0.02] and 19% in the obese category (OR 3.95, p = 0.04). Statin use was associated with severe or severe, complicated CDI when controlling for age and BMI (OR 5.66, p = 0.01). There was no association between statin use and IBD exacerbations following CDI. Opioid and antidepressant use were not associated with disease severity or frequency of IBD exacerbations following CDI.

CONCLUSIONS

An overweight BMI and statin use were associated with severe or severe, complicated CDI in IBD patients. Further studies are needed to better understand how these factors impact management of patients with IBD to improve clinical outcomes and potentially reduce the risk of complications from CDI.

Morbid Obesity Increases 30-Day Readmission and Morbidity in Clostridiodes difficile Infection

BACKGROUND

Readmission for patients hospitalized with Clostridioides difficile infections (CDIs) carries high morbidity, mortality, and burden on healthcare resources. This study aims to determine if morbid obesity is risk factor for 30-day readmission in patients hospitalized with CDI.

METHODS

This retrospective cohort study used the 2014 National Readmission Database. Included patients had a principal diagnosis of CDI and excluded if younger than 18 years of age or admitted during the month of December. Readmissions to any hospital for non-trauma diagnoses within 30 days of the index admission were included. The primary outcome was 30-day all cause readmission. Secondary outcomes were (1) in-hospital mortality; (2) morbidity, initiation of dialysis, or total parenteral nutrition; and (3) resource utilization during index admissions.

RESULTS

A total of 91,265 subjects were included in this study, 4388 of whom were morbidly obese. Morbid obesity was associated with significantly higher odds of readmission and was associated with higher adjusted mean total hospitalization charges and costs, higher odds of PMV, and acute renal failure requiring dialysis in individuals that develop CDI.

CONCLUSIONS

Morbid obesity is an independent risk factor for 30-day readmission in patients hospitalized for CDI. Morbidly obese patients admitted for CDI experienced higher morbidity and increased resource utilization.

Comparison of Real-World Outcomes of Infliximab versus Adalimumab in Biologic-Naïve Korean Patients with Ulcerative Colitis: A Population-Based Study

PURPOSE

Data on the comparative effectiveness of infliximab (IFX) or adalimumab (ADA) in patients with ulcerative colitis (UC) are extremely limited, especially in the Asian population. We compared clinically important outcomes [colectomy, UC-related emergency room (ER) visits, UC-related hospitalizations, and need for corticosteroids] for these two biologics in biologic-naïve Korean patients with UC.

MATERIALS AND METHODS

Using National Health Insurance claims, we collected data on patients who were diagnosed with UC and exposed to IFX or ADA between 2010 and 2016.

RESULTS

A total of 862 new users of biologics were included, of whom 630 were treated with IFX and 232 were treated with ADA. Over a median follow-up of 1.8 years after starting biologic therapy, there were no significant differences in the risk of colectomy [adjusted hazard ratio (aHR), 1.87; 95% confidence interval (CI), 0.30-11.63], ER visits (aHR, 1.58; 95% CI, 0.79-3.16), hospitalizations (aHR, 0.83; 95% CI, 0.59-1.17), and corticosteroid use (aHR, 1.16; 95% CI, 0.76-1.78) between IFX and ADA users. These results were stable even when only patients who used biologics for ≥6 months were analyzed. Additionally, these results were unchanged in patients treated with biologic monotherapy or combination therapy with immunomodulators.

CONCLUSION

In this nationwide population-based study, there was no significant difference in the risk of colectomy, ER visits, hospitalizations, and corticosteroid use between IFX and ADA users. Our findings indicate that IFX and ADA have comparable effectiveness in biologic-naïve Korean patients with UC.