Use of Concomitant Antibiotics During Treatment for Clostridium difficile Infection (CDI) in Pediatric Inpatients: An Observational Cohort Study

Improving Clostridioides difficile Infectious Disease Treatment Response via Adherence to Clinical Practice Guidelines

Clostridioides difficile (C. difficile) is a predominant nosocomial infection, and guidelines for improving diagnosis and treatment were published in 2017. We conducted a single-center, retrospective 10-year cohort study of patients with primary C. difficile infectious disease (CDID) at the largest referral Lithuanian university hospital, aiming to evaluate the clinical and laboratory characteristics of CDID and their association with the outcomes, as well as implication of concordance with current Clinical Practice Guidelines. The study enrolled a total of 370 patients. Cases with non-concordant CDID treatment resulted in more CDID-related Intensive Care Unit (ICU) admissions (7.5 vs. 1.8%) and higher CDID-related mortality (13.0 vs. 1.8%) as well as 30-day all-cause mortality (61.0 vs. 36.1%) and a lower 30-day survival compared with CDID cases with concordant treatment (p < 0.05). Among cases defined by two criteria for severe CDID, only patients with non-concordant metronidazole treatment had refractory CDID (68.8 vs. 0.0%) compared with concordant vancomycin treatment. In the presence of non-concordant metronidazole treatment for severe CDID, only cases defined by two severity criteria had more CDID-related ICU admissions (18.8 vs. 0.0%) and higher CDID-related mortality (25.0 vs. 2.0%, p < 0.05) compared with cases defined by one criterion. Severe comorbidities and the continuation of concomitant antibiotics administered at CDID onset reduced (p < 0.05) the 30-day survival and increased (p = 0.053) 30-day all-cause mortality, with 57.6 vs. 10.7% and 52.0 vs. 25.0%, respectively. Conclusions: CDID treatment non-concordant with the guidelines was associated with various adverse outcomes. In CDID with leukocytes ≥ 15 × 109/L and serum creatinine level > 133 µmol/L (>1.5 mg/dL), enteral vancomycin should be used to avoid refractory response, as metronidazole use was associated with CDID-related ICU admission and CDID-related mortality. Severe comorbidities worsened the outcomes as they were associated with reduced 30-day survival. The continuation of concomitant antibiotic therapy increased 30-day all-cause mortality; thus, it needs to be reasonably justified, deescalated or stopped.

Treatment of Clostridium difficile infection in community teaching hospital: a retrospective study

Objectives

Clostridium difficile infection (CDI) is responsible for 15–25% cases of health-care-associated diarrhea. The CDI treatment algorithm used at our hospital is adapted from the Infectious Diseases Society of America 2010 C. difficile guideline. The primary objective of this study was to assess the treatment adherence to our algorithm; this was defined as therapy consisting of the appropriate antibiotic, dose, route, interval, and duration indicated based on the disease severity and episode within 24 h of diagnosis. Furthermore, our study also described the population and their risk factors for CDI at our hospital.

Methods

This was a single-centre, retrospective cohort chart review of CDI cases that were diagnosed at admission or during hospitalization from June 1st, 2017 to June 30th, 2018. Cases were identified by a positive stool test along with watery diarrhea or by colonoscopy.

Results

Sixty cases were included, of which adherence to our algorithm was 50%. Overall, severe CDI had the highest treatment non-adherence (83%), and the biggest contributing factor was prescribing the wrong antibiotic (72%). In severe CDI, which warrants vancomycin monotherapy, wrong antibiotic consisted of metronidazole monotherapy (55%) or dual therapy with metronidazole and vancomycin (45%). Patients were mostly older, females being treated for an initial episode of mild-to-moderate CDI. Common risk factors identified were age over 65 years (80%), use of antibiotics (83%) and proton pump inhibitors (PPI) (68%) within the previous 3 months. The use of a PPI in this study, a modifiable risk factor without a clear indication, was 35%.

Conclusion

An area for antimicrobial stewardship intervention in CDI treatment at our hospital is prescribing the right antibiotic based on the CDI indication. In severe CDI, an emphasis should be on prescribing vancomycin monotherapy as the drug of choice. PPI use should be reassessed for tapering when appropriate.