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Ding UZ, Ooi L, Wu HHL, Chinnadurai R. Clostridioides difficile Infection in Kidney Transplant Recipients. Pathogens 2024; 13:140. [PMID: 38392878 PMCID: PMC10892420 DOI: 10.3390/pathogens13020140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
Clostridioides difficile (C. difficile) is a bacterial organism that typically infects the colon, which has had its homeostasis of healthy gut microbiota disrupted by antibiotics or other interventions. Patients with kidney transplantation are a group that are susceptible to C. difficile infection (CDI) and have poorer outcomes with CDI given that they conventionally require long-term immunosuppression to minimize their risk of graft rejection, weakening their responses to infection. Recognizing the risk factors and complex pathophysiological processes that exist between immunosuppression, dysbiosis, and CDI is important when making crucial clinical decisions surrounding the management of this vulnerable patient cohort. Despite the clinical importance of this topic, there are few studies that have evaluated CDI in the context of kidney transplant recipients and other solid organ transplant populations. The current recommendations on CDI management in kidney transplant and solid organ transplant recipients are mostly extrapolated from data relating to CDI management in the general population. We provide a narrative review that discusses the available evidence examining CDI in solid organ transplant recipients, with a particular focus on the kidney transplant recipient, from the epidemiology of CDI, clinical features and implications of CDI, potential risk factors of CDI, and, ultimately, prevention and management strategies for CDI, with the aim of providing areas for future research development in this topic area.
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Affiliation(s)
- UZhe Ding
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (U.D.); (L.O.); (R.C.)
| | - Lijin Ooi
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (U.D.); (L.O.); (R.C.)
| | - Henry H. L. Wu
- Renal Research Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, The University of Sydney, Sydney, NSW 2065, Australia
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (U.D.); (L.O.); (R.C.)
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK
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Fitzmaurice MG, Hohlfelder B, Srinivas P, Rudoni M, Brizendine KD, Budev M. Implementation of routine Clostridioides difficile infection (CDI) primary prophylaxis in lung transplant recipients. Clin Transplant 2023; 37:e15079. [PMID: 37477286 DOI: 10.1111/ctr.15079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 07/09/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
Lung transplant recipients are at an increased risk for Clostridioides difficile infection (CDI), and those who develop CDI post-transplant can have worsened outcomes including graft failure and death. We sought to describe the efficacy and safety of primary CDI prophylaxis with oral vancomycin among 86 adult lung transplant recipients. Overall, we observed a 9.3% (8/86) incidence of CDI among patients receiving prophylaxis, with the majority of infections occurring a median of 25 days after completion of prophylaxis. Furthermore, we observed a 4.7% incidence of VRE infection/colonization. Opportunities exist to optimize the duration of CDI prophylaxis to balance the benefits and risks in lung transplant recipients.
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Affiliation(s)
- Mary Grace Fitzmaurice
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Pharmacy and Transplant Institute, Henry Ford Health, Detroit, MI, USA
| | | | | | - Michael Rudoni
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kyle D Brizendine
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marie Budev
- Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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Clostridioides difficile Infection in Patients after Organ Transplantation—A Narrative Overview. J Clin Med 2022; 11:jcm11154365. [PMID: 35955980 PMCID: PMC9368854 DOI: 10.3390/jcm11154365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/03/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
Clostridioides difficile infection (CDI) is one of the most common causes of antibiotic-associated diarrhea. The pathogenesis of this infection participates in the unstable colonization of the intestines with the physiological microbiota. Solid-organ-transplant (SOT) patients and patients after hematopoietic stem cell transplantation are more prone to CDI compared to the general population. The main CDI risk factors in these patients are immunosuppressive therapy and frequent antibiotic use leading to dysbiosis. The current review article provides information about the risk factors, incidence and course of CDI in patients after liver, kidney, heart and lung transplantation and hematopoietic stem cell transplantation.
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Padiyar J. Critical care considerations in the post-operative period for the lung transplant patient. J Thorac Dis 2022; 13:6747-6753. [PMID: 34992850 PMCID: PMC8662514 DOI: 10.21037/jtd-21-1441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/17/2021] [Indexed: 11/07/2022]
Abstract
The post-operative management of a lung transplant recipient can be complex. Several factors including medical comorbidities, severity of illness at the time of transplant and intra-operative events can affect graft function and overall survival. During the immediate post-operative period, it becomes essential for early recognition of disease-specific sequelae as they can impact the patient’s outcome and quality of life. This often necessitates a multidisciplinary team of pulmonologists, surgeons, medical sub-specialists as well as skilled nurses and respiratory therapists familiar with caring for these patients. Based on the experiences of a high-volume transplant center, this chapter will outline key considerations within each organ system in this specific patient population in the Intensive Care Unit.
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Affiliation(s)
- Josna Padiyar
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Hosseini-Moghaddam SM, Luo B, Bota SE, Husain S, Silverman MS, Daneman N, Brown KA, Paterson JM. Incidence and Outcomes Associated With Clostridioides difficile Infection in Solid Organ Transplant Recipients. JAMA Netw Open 2021; 4:e2141089. [PMID: 34964852 PMCID: PMC8717111 DOI: 10.1001/jamanetworkopen.2021.41089] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Little is known about the incidence and outcomes of Clostridioides difficile infection (CDI) in solid organ transplant (SOT) recipients. OBJECTIVE To estimate the CDI incidence and outcomes in SOT recipients. DESIGN, SETTING, AND PARTICIPANTS A population-based cohort study was conducted using administrative health care data for all Ontario, Canada, residents who received organ allografts from April 1, 2003, to December 31, 2017; March 31, 2020, was the end of the study period. MAIN OUTCOMES AND MEASURES The primary outcome was hospital admission with CDI diagnosis. The secondary outcomes included all-cause death, intensive care unit admission, acute kidney injury requiring dialysis, and fulminant CDI comprising any of the following: toxic megacolon, ileus, perforation, or colectomy. The association between short- vs long-term mortality (ie, death occurring within or after 90 days post-CDI) and the following variables was evaluated: age, sex, Deyo-Charlson Comorbidity Index, SOT type, early- vs late-onset CDI, fulminant CDI, intensive care unit admission, and acute kidney injury requiring acute dialysis. RESULTS Overall, 10 724 SOT recipients (6901 [64.4%] men; median age, 54 [IQR, 44-62] years) were eligible. Kidney transplant was the most common SOT type (6453 [60.2%]). The median follow-up time was 5.0 (IQR, 2.3-8.8) years, resulting in 61 987 person-years of follow-up. A total of 726 patients (6.8%) were hospitalized with CDI. The 1-year CDI incidence significantly increased in annual cohorts (ie, from 23.1; 95% CI, 12.8-41.8 per 1000 person-years in 2004 to 46.7; 95% CI, 35.0-62.3 per 1000 person-years in 2017; P = .001). Clostridioides difficile was associated with a 16.8% rate (n = 122) of 90-day mortality. In patients who underwent kidney transplant, CDI was typically late-onset (median interval, 2.2; IQR, 0.4-6.0 years) compared with recipients of other organs. Acute kidney injury requiring dialysis was significantly associated with short-term (adjusted odds ratio [aOR], 1.86; 95% CI, 1.07-3.26) and long-term (adjusted hazard ratio [aHR], 1.89; 95% CI, 1.29-2.78) mortality, and late-onset CDI was also significantly associated with a greater risk of short-term (aOR, 4.26; 95% CI, 2.51-7.22) and long-term (aHR, 2.49; 95% CI, 1.78-3.49) mortality. CONCLUSIONS AND RELEVANCE In this study, increasing CDI trends in annual cohorts of SOT recipients were observed. Posttransplant CDI was associated with mortality, and late-onset CDI was associated with a greater risk of death than early-onset CDI. These findings suggest that preventive strategies should not be limited to the initial months following transplantation. Comprehensive therapeutic approaches targeting acute kidney injury risk factors in SOT recipients may reduce short- and long-term post-CDI mortality.
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Affiliation(s)
- Seyed M. Hosseini-Moghaddam
- ICES, Ontario, Canada
- Multiorgan Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, Western University, London, Ontario, Canada
| | | | | | - Shahid Husain
- Multiorgan Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael S. Silverman
- Division of Infectious Diseases, Department of Medicine, Western University, London, Ontario, Canada
| | - Nick Daneman
- ICES, Ontario, Canada
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - Kevin A. Brown
- ICES, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - J. Michael Paterson
- ICES, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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McCort M, MacKenzie E, Pursell K, Pitrak D. Bacterial infections in lung transplantation. J Thorac Dis 2021; 13:6654-6672. [PMID: 34992843 PMCID: PMC8662486 DOI: 10.21037/jtd-2021-12] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 02/18/2021] [Indexed: 12/30/2022]
Abstract
Lung transplantation has lower survival rates compared to other than other solid organ transplants (SOT) due to higher rates of infection and rejection-related complications, and bacterial infections (BI) are the most frequent infectious complications. Excess morbidity and mortality are not only a direct consequence of these BI, but so are subsequent loss of allograft tolerance, rejection, and chronic lung allograft dysfunction due to bronchiolitis obliterans syndrome (BOS). A wide variety of pathogens can cause infections in lung transplant recipients (LTRs), including a number of nosocomial pathogens and other multidrug-resistant (MDR) pathogens. Although pneumonia and intrathoracic infections predominate, LTRs are at risk of a number of types of infections. Risk factors include altered anatomy and function of airways, impaired immunity, the microbial flora of the donor and recipient, underlying medical conditions, and genetic factors. Further work on immune monitoring has the potential to improve outcomes. The infecting agents can be derived from the donor lung, pre-existing recipient flora, or acquired from the environment over time. Certain infections may preclude lung transplantation, but this varies from center to center, and more recent studies suggest fewer patients should be disqualified. New molecular methods allow microbiome studies of the lung, gut, and other sites that may further our knowledge of how airway colonization can result in infection and allograft loss. Surveillance, early diagnosis, and aggressive antimicrobial therapy of BI is critical in LTRs. Antibiotic resistance is a major barrier to successful management of these infections. The availability of new agents for MDR Gram-negatives may improve outcomes. Other new therapies, such as bacteriophage therapy, show promise for the future. Finally, it is important to prevent infections through peri-transplant prophylaxis, vaccination, and infection control measures.
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Affiliation(s)
- Margaret McCort
- Albert Einstein College of Medicine, Division of Infectious Disease, New York, NY, USA
| | - Erica MacKenzie
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
| | - Kenneth Pursell
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
| | - David Pitrak
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
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Clostridioides difficile colonization and infection in a cohort of Australian adults with cystic fibrosis. J Hosp Infect 2021; 113:44-51. [PMID: 33775742 DOI: 10.1016/j.jhin.2021.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Little is known about Clostridioides difficile infection (CDI) in patients with cystic fibrosis (CF). The aim of this study was to investigate the prevalence, molecular epidemiology and risk factors for CDI in asymptomatic and symptomatic adults with CF in Western Australia. METHODS Faecal samples from symptomatic and asymptomatic patients were prospectively collected and tested for the presence of C. difficile by toxigenic culture. Ribotyping was performed by established protocols. Logistic regression analysis was performed to analyse the risk factors for C. difficile colonization and infection. Extensive environmental sampling was performed within the CF clinic in Perth. RESULTS The prevalence rates of asymptomatic toxigenic and non-toxigenic C. difficile colonization were 30% (14/46 patients) and 24% (11/46 patients), respectively. Fifteen ribotypes (RTs) of C. difficile were identified, of which non-toxigenic RT 039 was the most common. Among the symptomatic patients, the prevalence of toxigenic CDI was 33% (11/33 patients). Impaired glucose tolerance/diabetes mellitus and duration of intravenous antibiotic use in the past 12 months were significantly associated with increased risk of asymptomatic toxigenic C. difficile carriage and CDI. A trend towards higher CF transmembrane conductance regulator modulator treatment was observed in the CDI group. Extensive environmental sampling showed no evidence of toxigenic C. difficile contamination within the CF clinic. CONCLUSIONS A high prevalence of asymptomatic carriage of toxigenic C. difficile was observed in adults with CF, comparable with that observed in the symptomatic CF population. There was no evidence of direct person-to-person transmission.
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Clostridium difficile disease in solid organ transplant recipients: a recommended treatment paradigm. Curr Opin Organ Transplant 2021; 25:357-363. [PMID: 32618715 DOI: 10.1097/mot.0000000000000778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Organ transplant recipients have an increased incidence of Clostridium difficile disease and lower clinical response rates compared with the general population. Transplant specific treatment approaches are not defined. Therefore, a review of therapeutics in the transplant population is needed. RECENT FINDINGS A literature review on the current therapies for C. difficile was performed focusing on the evidence in transplant recipients and immunosuppressed populations. SUMMARY Transplant patients warrant an aggressive approach to treatment. The authors propose a suggested treatment paradigm for therapy.
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Clostridioides difficile in transplant patients: early diagnosis, treatment, and prevention. Curr Opin Infect Dis 2020; 32:307-313. [PMID: 31116134 DOI: 10.1097/qco.0000000000000560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW Clostridioides difficile infection is common in solid organ transplant and hematopoietic stem-cell transplant recipients and is associated with significant morbidity and mortality. These populations are also underrepresented in clinical trials, making optimal management difficult. Because of this, management of these populations follows national guideline recommendations. This review aims to summarize the recent relevant literature pertaining to the clinical management of C. difficile infection in transplant patients, with a particular focus on diagnosis, treatment, and prevention. RECENT FINDINGS Early diagnosis of C. difficile colonization may mitigate both horizontal and vertical transmission (progression from colonization to colitis) of infection. Once diagnosed, recent literature suggests antibiotic treatment should align with that recommended by national guidelines. Fecal microbiota transplant is an emerging therapy for recurrent C. difficile infection, and recent data have demonstrated safety and efficacy. Prevention strategies including antimicrobial stewardship, probiotic administration, antibiotic administration, and bezlotoxumab may be beneficial in transplant populations, but more data are needed to confirm recent findings. SUMMARY Studies evaluating C. difficile infection in transplant patients are only recently starting to emerge. Further research is needed to identify optimal treatment and prevention strategies, and to examine novel strategies such as microbiome manipulation.
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Revolinski SL, Munoz-Price LS. Clostridium difficile in Immunocompromised Hosts: A Review of Epidemiology, Risk Factors, Treatment, and Prevention. Clin Infect Dis 2020; 68:2144-2153. [PMID: 30281082 DOI: 10.1093/cid/ciy845] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022] Open
Abstract
Clostridium difficile is a significant pathogen in healthcare today, impacting both hospitalized and community-based patients. Immunocompromised patients experience a high incidence of C. difficile infection, ranging from 6% to 33% in the hematology-oncology population and up to 23% among lung transplant recipients, and have a rate of 7.1-8.3 cases per 1000 patient-years in patients with human immunodeficiency virus (HIV). Recurrence of C. difficile infections among immunocompromised patients is also high, with rates up to 40% in both the hematology-oncology population and solid organ transplant recipients. This higher incidence of C. difficile infection and recurrence is believed to be secondary to frequent antimicrobial use, suppressed immune function, increased exposure to healthcare settings, and higher prevalence of C. difficile colonization. This review summarizes published data describing the epidemiology, risk factors for acquisition and infection, treatment, and prevention of C. difficile in hematology-oncology, solid organ transplant, and HIV-infected patients.
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Affiliation(s)
- Sara Lynn Revolinski
- Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee.,School of Pharmacy, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - L Silvia Munoz-Price
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee
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Okamoto K, Santos CAQ. Management and prophylaxis of bacterial and mycobacterial infections among lung transplant recipients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:413. [PMID: 32355857 PMCID: PMC7186743 DOI: 10.21037/atm.2020.01.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Bacterial and mycobacterial infections are associated with morbidity and mortality in lung transplant recipients. Infectious complications are categorized by timing post-transplant: <1, 1–6, and >6 months. The first month post-transplant is associated with the highest risk of infection. During this period, infections are most commonly healthcare-associated, and include infections related to surgical complications. The lungs and bloodstream are common sites of infections. Common healthcare-associated organisms include methicillin-resistant Staphylococcus aureus (MRSA), Gram-negative bacilli such as Pseudomonas aeruginosa, and Clostridioides difficile. More than 1-month post-transplant, opportunistic infections can occur. Tuberculosis occurs in 0.8–10% of lung transplant recipients which reflects variation in background prevalence. The majority of post-transplant tuberculosis stems from reactivation of untreated or undiagnosed latent tuberculosis. Most post-transplant tuberculosis occurs in the lungs and develops within a year of transplant. Non-tuberculous mycobacteria commonly colonize the lungs of lung transplant candidates and are often hard to eradicate even with prolonged courses of antimycobacterial agents. Drug interactions between antimycobacterial agents and calcineurin and mTOR inhibitors also complicates treatment post-transplant. Given that infection adversely impacts outcomes after lung transplant, and that anti-infective therapy is often less effective after transplant, infection prevention is key to long-term success. A comprehensive approach that includes pre-transplant evaluation, perioperative prophylaxis, long-term antimicrobial prophylaxis, immunization, and safer living at home and in the community, should be employed to minimize the risk of infection.
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Affiliation(s)
- Koh Okamoto
- Department of Infectious Diseases, University of Tokyo Hospital, Tokyo, Japan.,Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - Carlos A Q Santos
- Department of Infectious Diseases, University of Tokyo Hospital, Tokyo, Japan.,Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
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Avni T, Babitch T, Ben-Zvi H, Hijazi R, Ayada G, Atamna A, Bishara J. Clostridioides difficile infection in immunocompromised hospitalized patients is associated with a high recurrence rate. Int J Infect Dis 2019; 90:237-242. [PMID: 31672656 DOI: 10.1016/j.ijid.2019.10.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/20/2019] [Accepted: 10/22/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Clostridioides difficile infection (CDI) may pose a serious threat to immunocompromised patients (IMC). Herein, we evaluated the clinical outcomes of IMC patients with CDI. METHODS All consecutive hospitalized patients between January 1, 2013 and December 31, 2018 with laboratory confirmed CDI were included in the study. Subjects were divided into two groups: IMC patients and controls. Primary outcome was the recurrence rate of CDI (rCDI) at 30 and 90 days after the first CDI episode. Secondary outcomes included 30 and 90 day all-cause mortality, length of hospital stay (LOS) and readmission rates. A multivariate analysis adjusted other risk factors for recurrence. An analysis of IMC patient subgroups (based on type of IMC conditions) was also performed. Results are reported as odds ratios (OR) with a 95% confidence interval (95% CI). RESULTS A total of 573 patients were included, amongst them 149 IMC patients (36 solid organ transplants, 38 undergoing chemotherapy, 62 haematological conditions, 13 receiving high dose prednisone) and 424 controls. IMC patients were younger, independent and exhibited less significant comorbidities. On multivariable analysis, the rate of rCDI was significantly higher in IMC patients (OR 2.7, 95% CI 1.6-5). rCDI was also associated with vancomycin therapy, haemodialysis and previous hospitalizations. Mortality, LOS, CDI complications and rehospitalization rates were similar in both. CONCLUSIONS IMC patients with CDI have an increased risk of 90 days rCDI. Vancomycin treatment for CDI endangers recurrence in IMC patients. Further research should explore other therapies for IMC patients with CDI with alternative agents such as Fidaxomicin and Bezlotoxumab.
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Affiliation(s)
- Tomer Avni
- Infectious Disease Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Internal Medicine Department E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Tanya Babitch
- Internal Medicine Department E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Haim Ben-Zvi
- Clinical Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Rabab Hijazi
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Gida Ayada
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Alaa Atamna
- Infectious Disease Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.
| | - Jihad Bishara
- Infectious Disease Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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Angarone M, Snydman DR. Diagnosis and management of diarrhea in solid-organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13550. [PMID: 30913334 DOI: 10.1111/ctr.13550] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/30/2022]
Abstract
These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of diarrhea in the pre- and post-transplant period. Diarrhea in an organ transplant recipient may result in significant morbidity including dehydration, increased toxicity of medications, and rejection. Transplant recipients are affected by a wide range of etiologies of diarrhea with the most common causes being Clostridioides (formerly Clostridium) difficile infection, cytomegalovirus, and norovirus. Other bacterial, viral, and parasitic causes can result in diarrhea but are far less common. Further, noninfectious causes including medication toxicity, inflammatory bowel disease, post-transplant lymphoproliferative disease, and malignancy can also result in diarrhea in the transplant population. Management of diarrhea in this population is directed at the cause of the diarrhea, instituting therapy where appropriate and maintaining proper hydration. Identification of the cause to the diarrhea needs to be timely and focused.
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Affiliation(s)
- Michael Angarone
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David R Snydman
- Department of Medicine, The Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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Bajrovic V, Budev M, McCurry KR, Brizendine KD. Vancomycin prophylaxis for Clostridium difficile infection among lung transplant recipients. J Heart Lung Transplant 2019; 38:874-876. [DOI: 10.1016/j.healun.2019.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/13/2019] [Accepted: 05/18/2019] [Indexed: 10/26/2022] Open
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15
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Jorgenson MR, Descourouez JL, Yang DY, Leverson GE, Saddler CM, Smith JA, Safdar N, Mandlebrot DA, Redfield RR. Epidemiology, Risk Factors, and Outcomes After Early Posttransplant Clostridiodes difficile Infection in Renal Transplant Recipients. Ann Pharmacother 2019; 53:1020-1025. [PMID: 31007034 DOI: 10.1177/1060028019845003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Modifiable risk-factors associated with Clostridioides difficile infection (CDI) in renal-transplant (RTX) have not been clearly established and peri-transplant risk has not been described. OBJECTIVE Evaluate epidemiology, risk-factors and outcomes after CDI occurring in the first 90 days after RTX (CDI-90).Methods: Observational cohort study/survival analysis of adult RTX recipients from 1/1/2012-12/31/2015. Primary outcome was CDI-90 incidence/risk-factors. Secondary outcome was evaluation of post-90 day transplant outcomes. RESULTS 982 patients met inclusion criteria; 46 with CDI-90 and 936 without (comparator). CDI incidence in the total population was 4.7% at 90 days, 6.3% at 1 year, and 6.4% at 3 years. Incidence of CDI-90 was 5%; time to diagnosis was 19.4±25 days (median 7). Risk-factors for CDI-90 were alemtuzumab induction (Hazard ratio [HR] 1.5, 95% CI(1.1-2.0), p = 0.005) and age at transplant (HR 1.007/year, 95% CI (1.002-1.012), p= 0.007). However, risk-factors for CDI at any time were different; donation-after-circulatory-death (DCD) donor (HR 2.5 95% CI (1.3-4.9), p = 0.008) and female gender (HR 1.6 95% CI (1.0-2.7), p = 0.049). On Kaplan-Meier, CDI-90 appeared to have an impact on patient/graft survival, however when analyzed in a multivariable stepwise Cox proportional hazards model, only age was significantly associated with survival (p = 0.002). CONCLUSION AND RELEVANCE Incidence of CDI-90 is low, mostly occurring in the first post-operative month. Risk-factors vary temporally based on time from transplant. In the early post-op period induction agent and age at transplant are significant, but not after. Associations between CDI and negative graft outcomes appear to be largely driven by age. Future studies validating these risk-factors as well as targeted prophylaxis strategies and their effect on long term graft outcomes and the host microbiome are needed.
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Affiliation(s)
| | | | - Dou-Yan Yang
- 1 University of Wisconsin Hospital and Clinics, Madison WI, USA.,2 University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Glen E Leverson
- 1 University of Wisconsin Hospital and Clinics, Madison WI, USA.,2 University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Christopher M Saddler
- 1 University of Wisconsin Hospital and Clinics, Madison WI, USA.,2 University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Jeannina A Smith
- 1 University of Wisconsin Hospital and Clinics, Madison WI, USA.,2 University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Nasia Safdar
- 1 University of Wisconsin Hospital and Clinics, Madison WI, USA.,2 University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Didier A Mandlebrot
- 1 University of Wisconsin Hospital and Clinics, Madison WI, USA.,2 University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
| | - Robert R Redfield
- 1 University of Wisconsin Hospital and Clinics, Madison WI, USA.,2 University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
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16
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Pouch SM, Friedman-Moraco RJ. Prevention and Treatment of Clostridium difficile-Associated Diarrhea in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:733-748. [PMID: 30146033 DOI: 10.1016/j.idc.2018.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection is a significant cause of morbidity and mortality in solid organ transplant recipients. Risk factors in this population include frequent hospitalizations, receipt of immunosuppressive agents, and intestinal dysbiosis triggered by several factors, including exposure to broad-spectrum antimicrobials. The incidence and potential for significant adverse outcomes among solid organ transplant recipients with C difficile infection highlight the evolving need for strategic C difficile infection risk factor modification and novel approaches to disease management in this patient population. This review focuses on current concepts related to the prevention and treatment of C difficile infection in solid organ transplant recipients.
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Affiliation(s)
- Stephanie M Pouch
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA.
| | - Rachel J Friedman-Moraco
- Division of Infectious Diseases, Emory University School of Medicine, 101 Woodruff Circle, WMB #2101, Atlanta, GA 30322, USA
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17
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Lin SC, Alonso CD, Moss AC. Fecal microbiota transplantation for recurrent Clostridium difficile infection in patients with solid organ transplants: an institutional experience and review of the literature. Transpl Infect Dis 2018; 20:e12967. [PMID: 30011107 DOI: 10.1111/tid.12967] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/19/2018] [Accepted: 07/12/2018] [Indexed: 12/26/2022]
Abstract
Clostridium difficile, an anaerobic gram-positive, spore-forming bacillus, has become the most common cause of nosocomial infectious diarrhea, and is associated with increased mortality in all populations. Patients who have received solid organ transplants (SOT) are at increased risk of Clostridium difficile infection (CDI) and CDI recurrence (rCDI). This may be related to chronic immunosuppression, frequent antibiotic exposure, and increased or prolonged hospitalizations. Increased morbidity and mortality from CDI is well-described in SOT patients. Conventional treatments for index and recurrent CDI include vancomycin and fidaxomicin. Fecal microbiota transplantation has emerged as an effective and safe alternative for treating rCDI in the general population. Reports of its safety in certain immunocompromised populations, such as those with inflammatory bowel disease, appear reassuring, but outcomes among SOT patients are less well known. Here, we summarize the experiences published to date on the treatment of rCDI with FMT in SOT patient, and also describe our detailed FMT protocol and experience in treating a series of SOT patients with rCDI. In addition to reporting the safety and efficacy of our FMT experience, we also discuss the diagnostic challenges and considerations in this population of solid organ transplant recipients.
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Affiliation(s)
- Steven C Lin
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carolyn D Alonso
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alan C Moss
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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18
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Cusini A, Béguelin C, Stampf S, Boggian K, Garzoni C, Koller M, Manuel O, Meylan P, Mueller NJ, Hirsch HH, Weisser M, Berger C, van Delden C. Clostridium difficile infection is associated with graft loss in solid organ transplant recipients. Am J Transplant 2018; 18:1745-1754. [PMID: 29349869 DOI: 10.1111/ajt.14640] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 12/10/2017] [Accepted: 12/12/2017] [Indexed: 01/25/2023]
Abstract
Clostridium difficile infection (CDI) is a leading cause of infectious diarrhea in solid organ transplant recipients (SOT). We aimed to assess incidence, risk factors, and outcome of CDI within the Swiss Transplant Cohort Study (STCS). We performed a case-control study of SOT recipients in the STCS diagnosed with CDI between May 2008 and August 2013. We matched 2 control subjects per case by age at transplantation, sex, and transplanted organ. A multivariable analysis was performed using conditional logistic regression to identify risk factors and evaluate outcome of CDI. Two thousand one hundred fifty-eight SOT recipients, comprising 87 cases of CDI and 174 matched controls were included. The overall CDI rate per 10 000 patient days was 0.47 (95% confidence interval ([CI] 0.38-0.58), with the highest rate in lung (1.48, 95% CI 0.93-2.24). In multivariable analysis, proven infections (hazard ratio [HR] 2.82, 95% CI 1.29-6.19) and antibiotic treatments (HR 4.51, 95% CI 2.03-10.0) during the preceding 3 months were independently associated with the development of CDI. Despite mild clinical presentations, recipients acquiring CDI posttransplantation had an increased risk of graft loss (HR 2.24, 95% CI 1.15-4.37; P = .02). These findings may help to improve the management of SOT recipients.
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Affiliation(s)
- A Cusini
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland.,Division of Infectious Diseases, Cantonal Hospital Chur, Chur, Switzerland
| | - C Béguelin
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - S Stampf
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - K Boggian
- Division of Infectious Diseases & Hospital Hygiene, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - C Garzoni
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland.,Clinic of Internal Medicine & Infectious Diseases, Clinica Luganese, Lugano, Switzerland
| | - M Koller
- Division of Infectious Diseases & Hospital Hygiene, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - O Manuel
- Infectious Diseases Service, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - P Meylan
- Infectious Diseases Service, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - N J Mueller
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital, University of Zürich, Zürich, Switzerland
| | - H H Hirsch
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - M Weisser
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - C Berger
- Division of Infectious Diseases and Hospital Epidemiology, University Children's Hospital Zürich, Zürich, Switzerland
| | - C van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
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19
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Korayem GB, Eljaaly K, Matthias KR, Zangeneh TT. Oral Vancomycin Monotherapy Versus Combination Therapy in Solid Organ Transplant Recipients With Uncomplicated Clostridium difficile Infection: A Retrospective Cohort Study. Transplant Proc 2018; 50:137-141. [PMID: 29407296 DOI: 10.1016/j.transproceed.2017.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/11/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Solid organ transplant (SOT) recipients are at high risk of Clostridium difficile infection (CDI) and CDI recurrence due to their suppressed immune systems and antibiotic exposure. A combination of metronidazole and oral vancomycin is often prescribed for SOT recipients with uncomplicated CDI despite any clinical practice guidelines supporting the need for combination therapy. This study aims to compare the CDI recurrence rates of metronidazole/vancomycin combination therapy to oral vancomycin monotherapy in SOT recipients after a first episode of uncomplicated CDI. METHODS A single-center retrospective cohort study evaluated SOT recipients diagnosed with uncomplicated CDI who were treated with vancomycin monotherapy or vancomycin/metronidazole combination therapy. The primary endpoint was CDI recurrence defined as a second CDI episode within 8 weeks of completing index CDI therapy. The secondary endpoints were time between the end of CDI therapy and recurrence, length of total hospitalization after the index CDI, and length of hospitalization after index CDI diagnosis. RESULTS Fifteen patients (25%) of 61 subjects experienced CDI recurrence. There was no statistically significant difference in CDI recurrence rate between the vancomycin monotherapy group and combination therapy group (23% versus 27%, respectively; P = .715). The median total length of hospitalization between the vancomycin monotherapy and combination therapy groups was statistically significant (9 versus 14 days, respectively; P = .047). DISCUSSION There was no difference found in recurrence rate between oral vancomycin monotherapy versus combination therapy. The study result weakens the practice of prescribing combination therapy for uncomplicated CDI in SOT recipients.
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Affiliation(s)
- G B Korayem
- Department of Pharmaceutical Practices, Princes Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona.
| | - K Eljaaly
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona; Department of Clinical Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - K R Matthias
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona; Banner - University Medical Center Tucson, Tucson, Arizona
| | - T T Zangeneh
- Banner - University Medical Center Tucson, Tucson, Arizona; Division of Infectious Diseases, Department of Medicine, University of Arizona, Tucson, Arizona
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20
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Nguyen CT, Li J, Anders S, Garcia-Diaz J, Staffeld-Coit C, Hand J. Comparison of outcomes with vancomycin or metronidazole for mild-to-moderate Clostridium difficile associated diarrhea among solid organ transplant recipients: A retrospective cohort study. Transpl Infect Dis 2018; 20:e12867. [PMID: 29512244 DOI: 10.1111/tid.12867] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/11/2017] [Accepted: 01/07/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Current guidelines recommend oral vancomycin or fidaxomicin for the treatment of mild-to-moderate Clostridium difficile associated diarrhea (CDAD), while metronidazole is recommended as an alternative when oral vancomycin and fidaxomicin are unavailable. However, data are lacking among the solid organ transplant (SOT) population. METHODS This single center, retrospective cohort study evaluated adult SOT recipients with mild-to-moderate CDAD. Analysis 1 evaluated patients receiving initial therapy with metronidazole vs oral vancomycin for at least 72 hours. Analysis 2 evaluated patients receiving metronidazole vs oral vancomycin for at least 70% of the treatment duration. The primary outcome was treatment failure. Secondary outcomes included CDAD recurrence and all-cause mortality. RESULTS Analysis 1 included 71 patients (metronidazole n = 50, oral vancomycin n = 21) and analysis 2 included 75 patients (metronidazole n = 42, oral vancomycin n = 33). No significant differences in C. difficile risk factors were observed between groups in either analysis. However, in both analyses, more patients in the oral vancomycin arm received antibiotics during the CDAD episode (analysis 1, 52% vs 26%, P = .03; analysis 2, 55% vs 32%, P < .01). Neither analysis demonstrated differences in treatment failure (analysis 1, metronidazole 16%, oral vancomycin 10%, P = .71; analysis 2, metronidazole 2%, oral vancomycin 6%, P = .58). CDAD recurrence and all-cause mortality were similar across groups in both analyses. CONCLUSIONS Results suggest that both metronidazole and oral vancomycin are reasonable options for the treatment of mild-to-moderate CDAD in patients with SOT. No difference in treatment failure was observed; however, oral vancomycin may be preferred for higher risk patients, such as those receiving concurrent antibiotics.
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Affiliation(s)
- Cynthia T Nguyen
- Department of Pharmacy, Ochsner Medical Center, New Orleans, LA, USA
| | - Julius Li
- Department of Pharmacy, Ochsner Medical Center, New Orleans, LA, USA
| | - Stephanie Anders
- Department of Pharmacy, Ochsner Medical Center, New Orleans, LA, USA
| | - Julia Garcia-Diaz
- Department of Infectious Diseases, Ochsner Medical Center, New Orleans, LA, USA.,University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA
| | - Catherine Staffeld-Coit
- University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA.,Ochsner Multi-Organ Transplant Institute, Ochsner Medical Center, New Orleans, LA, USA
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Medical Center, New Orleans, LA, USA.,University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, USA
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21
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Dubberke ER, Reske KA, Olsen MA, Bommarito K, Cleveland AA, Silveira FP, Schuster MG, Kauffman CA, Avery RK, Pappas PG, Chiller TM. Epidemiology and outcomes of Clostridium difficile infection in allogeneic hematopoietic cell and lung transplant recipients. Transpl Infect Dis 2018; 20:e12855. [PMID: 29427356 DOI: 10.1111/tid.12855] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/29/2017] [Accepted: 11/07/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a common complication of lung and allogeneic hematopoietic cell (HCT) transplant, but the epidemiology and outcomes of CDI after transplant are poorly described. METHODS We performed a prospective, multicenter study of CDI within 365 days post-allogeneic HCT or lung transplantation. Data were collected via patient interviews and medical chart review. Participants were followed weekly in the 12 weeks post-transplant and while hospitalized and contacted monthly up to 18 months post-transplantation. RESULTS Six sites participated in the study with 614 total participants; 4 enrolled allogeneic HCT (385 participants) and 5 enrolled lung transplant recipients (229 participants). One hundred and fifty CDI cases occurred within 1 year of transplantation; the incidence among lung transplant recipients was 13.1% and among allogeneic HCTs was 31.2%. Median time to CDI was significantly shorter among allogeneic HCT than lung transplant recipients (27 days vs 90 days; P = .037). CDI was associated with significantly higher mortality from 31 to 180 days post-index date among the allogeneic HCT recipients (Hazard ratio [HR] = 1.80; P = .007). There was a trend towards increased mortality among lung transplant recipients from 120 to 180 days post-index date (HR = 4.7, P = .09). CONCLUSIONS The epidemiology and outcomes of CDI vary by transplant population; surveillance for CDI should continue beyond the immediate post-transplant period.
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Affiliation(s)
- E R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - K A Reske
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - M A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - K Bommarito
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - A A Cleveland
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - F P Silveira
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
| | - M G Schuster
- University of Pennsylvania, Philadelphia, PA, USA
| | - C A Kauffman
- VA Ann Arbor Healthcare System, University of Michigan Medical School, Ann Arbor, MI, USA
| | - R K Avery
- Johns Hopkins University, Baltimore, MD, USA
| | - P G Pappas
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - T M Chiller
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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22
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Snell G, Reed A, Stern M, Hadjiliadis D. The evolution of lung transplantation for cystic fibrosis: A 2017 update. J Cyst Fibros 2017; 16:553-564. [DOI: 10.1016/j.jcf.2017.06.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 06/29/2017] [Accepted: 06/29/2017] [Indexed: 02/08/2023]
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23
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Bruminhent J, Cawcutt KA, Thongprayoon C, Petterson TM, Kremers WK, Razonable RR. Epidemiology, risk factors, and outcome of Clostridium difficile infection in heart and heart-lung transplant recipients. Clin Transplant 2017; 31. [PMID: 28314071 DOI: 10.1111/ctr.12968] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clostridium difficile is a major cause of diarrhea in thoracic organ transplant recipients. We investigated the epidemiology, risk factors, and outcome of Clostridium difficile infection (CDI) in heart and heart-lung transplant (HT) recipients. METHODS This is a retrospective study from 2004 to 2013. CDI was defined by diarrhea and a positive toxigenic C. difficile in stool measured by toxin enzyme immunoassay (2004-2006) or polymerase chain reaction (2007-2013). Cox proportional hazards regression was used to model the association of risk factors with time to CDI and survival with CDI following transplantation. RESULTS There were 254 HT recipients, with a median age of 53 years (IQR, 45-60); 34% were female. During the median follow-up of 3.1 years (IQR, 1.3-6.1), 22 (8.7%) patients developed CDI. In multivariable analysis, risk factors for CDI were combined heart-lung transplant (HR 4.70; 95% CI, 1.30-17.01 [P=.02]) and retransplantation (HR 7.19; 95% CI, 1.61-32.12 [P=.01]). Acute cellular rejection was associated with a lower risk of CDI (HR 0.34; 95% CI, 0.11-0.94 [P=.04]). CDI was found to be an independent risk factor for mortality (HR 7.66; 95% CI, 3.41-17.21 [P<.0001]). CONCLUSIONS Clostridium difficile infection after HT is more common among patients with combined heart-lung and those undergoing retransplantation. CDI was associated with a higher risk of mortality in HT recipients.
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Affiliation(s)
- Jackrapong Bruminhent
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelly A Cawcutt
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Tanya M Petterson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter K Kremers
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA.,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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24
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Abstract
Clostridium difficile infections (CDIs) have emerged as one of the principal threats to the health of hospitalized and immunocompromised patients. The importance of C difficile colonization is increasingly recognized not only as a source for false-positive clinical testing but also as a source of new infections within hospitals and other health care environments. In the last five years, several new treatment strategies that capitalize on the increasing understanding of the altered microbiome and host defenses in patients with CDI have completed clinical trials, including fecal microbiota transplantation. This article highlights the changing epidemiology, laboratory diagnostics, pathogenesis, and treatment of CDI.
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25
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Banga A, Mohanka M, Mullins J, Bollineni S, Kaza V, Ring S, Bajona P, Peltz M, Wait M, Torres F. Hospital length of stay after lung transplantation: Independent predictors and association with early and late survival. J Heart Lung Transplant 2016; 36:289-296. [PMID: 27642060 DOI: 10.1016/j.healun.2016.07.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/26/2016] [Accepted: 07/31/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Duration of index hospitalization after lung transplantation (LTx) is an important variable that has not received much attention. We sought to determine independent predictors of prolonged hospital length of stay (LOS) and its association with early and late outcomes. METHODS The United Network of Organ Sharing database was queried for adult patients undergoing LTx between 2006 and 2014 (N = 14,320). Patients with dual organ or previous transplantation and patients who died during the first 25 days after LTx were excluded (n = 12,647, mean age 55.2 years ± 13.1). Primary outcome was prolonged LOS (>25 days) (3,251/12,647; 25.7%). Donor, recipient, and procedure-related variables were analyzed as potential predictors of prolonged LOS. Association of prolonged LOS with 1-year and 5-year survival was evaluated using Cox proportional hazards analysis. RESULTS Independent predictors of prolonged LOS included serum albumin, lung allocation score, functional status, and need of extracorporeal membrane oxygenation or ventilator support at the time of transplant; donor age >40 years; gender mismatch (female donor to male recipient); donor body mass index; African American ethnicity; ischemic time >6 hours; and double LTx. Prolonged LOS was independently associated with increased mortality at 1 year (hazard ratio, 3.96; 95% confidence interval, 3.48-4.50; p < 0.001) and 5 years (hazard ratio, 2.00; 95% confidence interval, 1.79-2.25; p < 0.001). CONCLUSIONS A significant proportion of patients have a prolonged LOS after LTx, and several recipient, donor, and procedure-related variables are independent predictors of this outcome. Patients with prolonged LOS after LTx have significantly increased risk of death at 1 year and 5 years.
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Affiliation(s)
- Amit Banga
- Division of Pulmonary and Critical Care Medicine.
| | | | | | | | - Vaidehi Kaza
- Division of Pulmonary and Critical Care Medicine
| | - Steve Ring
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pietro Bajona
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Wait
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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26
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Whiddon AR, Dawson KL, Fuentes A, Perez KK, Peterson LE, Kaleekal T. Postoperative antimicrobials after lung transplantation and the development of multidrug-resistant bacterial andClostridium difficileinfections: an analysis of 500 non-cystic fibrosis lung transplant patients. Clin Transplant 2016; 30:767-73. [DOI: 10.1111/ctr.12746] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 12/25/2022]
Affiliation(s)
| | | | - Amaris Fuentes
- CHI St. Luke's Health - Baylor St. Luke's Medical Center; Houston TX USA
| | - Katherine K. Perez
- Houston Methodist Hospital; Houston TX USA
- Houston Methodist Research Institute; Houston TX USA
| | - Leif E. Peterson
- Houston Methodist Hospital; Houston TX USA
- Houston Methodist Research Institute; Houston TX USA
| | - Thomas Kaleekal
- Houston Methodist Hospital; Houston TX USA
- Houston Methodist Research Institute; Houston TX USA
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27
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Abstract
PURPOSE OF REVIEW Clostridium difficile infection (CDI) is one of the most common healthcare-associated infections, and the threat associated with CDI continues to grow in all patient populations. There is increasing evidence that CDI has a substantial impact on the morbidity and mortality in solid organ transplant (SOT) recipients. Furthermore, new diagnostic and treatment options and strategies for CDI have emerged over the last decade. The purpose of this review is to provide a general understanding of CDI and its evidence-based diagnosis and management strategies, with a focus on SOT recipients. RECENT FINDINGS The incidence and severity of CDI have significantly increased since the year 2000. Studies have identified novel risk factors for CDI, and a new epidemic strain, the NAP1/BI/027, has emerged. Despite the development of newer testing methods and approaches, including nucleic acid amplification tests and testing algorithms, the optimal method for diagnosing CDI is an area of controversy. New agents for treating CDI are being developed, and the use of fecal microbiota transplantation to treat recurrent CDI in SOT recipients is also evolving. SUMMARY CDI is a significant problem for SOT recipients. Further studies on diagnostic and therapeutic strategies with a focus on SOT recipients are needed to further improve patient outcomes.
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28
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Abstract
PURPOSE OF REVIEW Diarrhea is a common complaint in the solid organ transplant recipient. Unlike the immune-competent patient, diarrhea in an organ transplant recipient may result in dehydration, increased toxicity of medications, and rejection. There is a wide range of causes for diarrhea in transplant recipients, but the most common causes are Clostridium difficile infection, cytomegalovirus, and norovirus. This review will focus on new epidemiology data as to the cause of diarrhea in the transplant population. RECENT FINDINGS Recent data have identified C. difficile, cytomegalovirus, and norovirus as important causes of diarrhea in this population, and management should be focused on these causes. Newer diagnostic platforms (such as PCR) are being evaluated, which may help in identification of the cause of diarrhea. SUMMARY New epidemiologic data and new testing techniques offer an opportunity for research into better testing strategies for transplant patients with diarrhea. These newer testing strategies may offer better insight into the cause of diarrhea and more appropriate treatment for this illness.
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Affiliation(s)
- Michael Angarone
- aDivision of Infectious Diseases bDivision of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Paudel S, Zacharioudakis IM, Zervou FN, Ziakas PD, Mylonakis E. Prevalence of Clostridium difficile infection among solid organ transplant recipients: a meta-analysis of published studies. PLoS One 2015; 10:e0124483. [PMID: 25886133 PMCID: PMC4401454 DOI: 10.1371/journal.pone.0124483] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 03/02/2015] [Indexed: 01/10/2023] Open
Abstract
Several factors including antibiotic use, immunosuppression and frequent hospitalizations make solid organ transplant (SOT) recipients vulnerable to Clostridium difficile infection (CDI). We conducted a meta-analysis of published studies from 1991-2014 to estimate the prevalence of CDI in this patient population. We searched PubMed, EMBASE and Google Scholar databases. Among the 75,940 retrieved citations, we found 30 studies coded from 35 articles that were relevant to our study. Based on these studies, we estimated the prevalence of CDI among 21,683 patients who underwent transplantation of kidney, liver, lungs, heart, pancreas, intestine or more than one organ and stratified each study based on the type of transplanted organ, place of the study conduction, and size of patient population. The overall estimated prevalence in SOT recipients was 7.4% [95%CI, (5.6-9.5%)] and it varied based on the type of organ transplant. The prevalence was 12.7% [95%CI, (6.4%-20.9%)] among patients who underwent transplantation for more than one organ. The prevalence among other SOT recipients was: lung 10.8% [95% CI, (5.5%-17.7%)], liver 9.1 % [95%CI, (5.8%-13.2%)], intestine 8% [95% CI, (2.6%-15.9%)], heart 5.2% [95%CI, (1.8%-10.2%)], kidney 4.7% [95% CI, (2.6%-7.3%)], and pancreas 3.2% [95% CI, (0.5%-7.9%)]. Among the studies that reported relevant data, the estimated prevalence of severe CDI was 5.3% [95% CI (2.3%-9.3%)] and the overall recurrence rate was 19.7% [95% CI, (13.7%-26.6%)]. In summary, CDI is a significant complication after SOT and preventive strategies are important in order to reduce the CDI related morbidity and mortality.
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Affiliation(s)
- Suresh Paudel
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Ioannis M. Zacharioudakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Fainareti N. Zervou
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Panayiotis D. Ziakas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, United States of America
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Di Bella S, Gouliouris T, Petrosillo N. Fecal microbiota transplantation (FMT) for Clostridium difficile infection: focus on immunocompromised patients. J Infect Chemother 2015; 21:230-7. [PMID: 25703532 DOI: 10.1016/j.jiac.2015.01.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 12/18/2022]
Abstract
Clostridium difficile infection (CDI) is an emerging problem worldwide associated with significant morbidity, mortality, recurrence rates and healthcare costs. Immunosuppressed patients, including HIV-seropositive individuals, solid organ transplant recipients, patients with malignancies, hematopoietic stem cell transplant recipients, and patients with inflammatory bowel disease are increasingly recognized as being at higher risk of developing CDI where it may be associated with significant complications, recurrence, and mortality. Fecal microbiota transplantation (FMT) has proven to be an effective and safe procedure for the treatment of recurrent or refractory CDI in immunocompetent patients by restoring the gut microbiota and resistance to further recurrences. During the last two years the first data on FMT in immunocompromised patients began to appear in the medical literature. Herein we summarize the use of FMT for the treatment of CDI with a focus on immunocompromised patients.
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Affiliation(s)
- Stefano Di Bella
- 2nd Division, National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy.
| | - Theodore Gouliouris
- Department of Infectious Diseases, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Nicola Petrosillo
- 2nd Division, National Institute for Infectious Diseases "L. Spallanzani", Rome, Italy
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Origüen J, Fernández-Ruiz M, Lumbreras C, Orellana MÁ, López-Medrano F, Ruiz-Merlo T, San Juan R, García-Reyne A, González E, Polanco N, Paz-Artal E, Andrés A, Aguado JM. Potential role of post-transplant hypogammaglobulinemia in the risk of Clostridium difficile infection after kidney transplantation: a case-control study. Infection 2015; 43:413-22. [PMID: 25676130 DOI: 10.1007/s15010-015-0737-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 01/27/2015] [Indexed: 12/16/2022]
Abstract
PURPOSE To identify reversible risk factors for Clostridium difficile infection (CDI) after kidney transplantation (KT) that could lead to a reduction in its incidence and associated complications. METHODS We performed a single-center case-control study in which 41 patients undergoing KT between February 2009 and July 2013 who developed a first episode of post-transplant CDI were included as cases. Patients transplanted at the same calendar day (± 2 weeks) as each case with no evidence of CDI and comparable risk exposure period were chosen as controls (2:1 ratio). Serum immunoglobulin and complement levels were systematically measured at baseline and months 1 and 6 after transplantation. RESULTS Multivariate regression analysis identified age-adjusted Charlson comorbidity index (odds ratio [OR] per unitary increment 1.31; P value = 0.043), delayed graft function (OR 2.76; P value = 0.039), prior cytomegalovirus (CMV) disease (OR 6.85; P value = 0.011) and prior acute graft rejection (OR 5.92; P value = 0.008) as risk factors for post-transplant CDI. Cases with their first episode of CDI occurring beyond the first month were more likely to have IgG hypogammaglobulinemia (HGG) at month 1 (P value = 0.002), whereas cases with CDI beyond the sixth month were more likely to have HGG of any class at month 6 (P value = 0.003). Poor outcome (graft loss and/or all-cause mortality) was more common among cases (adjusted hazard ratio 5.69; P value = 0.001). CONCLUSION The occurrence of CDI exerts a detrimental effect on graft and patient outcome. Post-transplant HGG was a potentially modifiable risk factor for CDI in KT recipients.
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Affiliation(s)
- Julia Origüen
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre" (Centro de Actividades Ambulatorias, 2ª planta, bloque D, Avda. de Córdoba, s/n, 28041), Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain,
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Clostridium difficile Infection (CDI) in Solid Organ and Hematopoietic Stem Cell Transplant Recipients. Curr Infect Dis Rep 2014; 16:414. [DOI: 10.1007/s11908-014-0414-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Hsu JL, Enser JJ, McKown T, Leverson GE, Pirsch JD, Hess TM, Safdar N. Outcomes of Clostridium difficile infection in recipients of solid abdominal organ transplants. Clin Transplant 2014; 28:267-73. [PMID: 24476412 DOI: 10.1111/ctr.12309] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2013] [Indexed: 12/15/2022]
Abstract
Knowledge of outcomes of Clostridium difficile infection (CDI) in solid organ transplant (SOT) recipients is limited. To evaluate this population, we undertook a retrospective cohort study of all recipients of kidney and liver transplants diagnosed with CDI at a single center over 14 yr. Data pertaining to all episodes of CDI were collected. Multivariate analysis using logistic regression was performed to determine independent predictors of clinical cure. Overall, 170 patients developed 215 episodes of CDI. Among these patients, 162 episodes (75%) were cured, and in 103 episodes (48%), patients were cured within 14 d. In a multivariate analysis, lack of clinical cure at 14 d was predicted by recurrent episode (0.21, 95% CI 0.06-0.72, p = 0.0128), treatment with vancomycin (OR 0.27, 95% CI 0.1-0.74, p = 0.011), vasopressor support (OR 0.23, 95% CI 0.07-0.76, p = 0.0161), and CDI before the year 2004 (OR 0.44, 95% CI 0.2-0.98, p = 0.0446). The latter three factors are likely markers for severity of illness. In this cohort, 13 patients (8%) died during hospitalization, and 49 patients (29%) died within one yr. No deaths were attributed to CDI. Recurrent episode was a major predictor of treatment failure, suggesting that research into development of therapeutic options for recurrent disease is needed.
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Affiliation(s)
- Jennifer L Hsu
- Division of Infectious Disease, Sanford Health and Sanford School of Medicine of The University of South Dakota, Sioux Falls, SD, USA
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Dawson KL, Mooney ML. Clostridium difficile infection after lung transplantation: Are we really doing everything possible? J Heart Lung Transplant 2013; 32:1002-4. [DOI: 10.1016/j.healun.2013.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 07/16/2013] [Indexed: 11/16/2022] Open
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Abstract
Clostridium difficile has re-emerged as a major hospital-acquired infection since 2001. Despite development of polymerase chain reaction-based testing, no single clinical diagnostic test has emerged with sufficient sensitivity, specificity, and turnaround time to be entirely reliable for disease diagnosis. The importance of C difficile acquired outside the hospital environment remains an unknown factor and awaits further epidemiologic investigation. This article discusses the changing epidemiology, clinical presentation, and pathogenesis of C difficile infection and highlights the ongoing challenges of laboratory diagnosis, treatment, and disease relapse.
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