The Impact of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers in patients with Clostridium difficile infection

Outcomes of Clostridioides difficile infection in acute heart failure hospitalizations: insights from the National Inpatient Database

BACKGROUND

Heart failure (HF) patients are at a greater risk for nosocomial infections due to their higher prevalence of comorbidities, readmission rates, and prolonged hospital stays. Clostridioides difficile infection (CDI) remains a common nosocomial infection in hospitalized patients.

AIM

To identify patients with a diagnosis of acute HF and stratified based on the presence of CDI, using the National Inpatient Sample (NIS) database from 2016 to 2020.

METHODS

Adjusted odds ratios (aOR) of in-hospital outcomes were calculated, and a propensity-matched analysis was performed.

FINDINGS

Of 536,595 acute HF hospitalizations in this timeframe, 3030 were also diagnosed with CDI (0.56%). Patients with acute HF and CDI had significantly higher in-hospital mortality (adjusted odds ratio: (aOR): 1.91), cardiac arrest (aOR: 1.66), and use of mechanical circulatory support (MCS) (aOR 2.42). In propensity-matched analysis, in-hospital mortality (13.71 vs 8.44%; P=0.005), septic shock (7.54 vs 3.33%; P=0.002), and use of MCS (7.19 vs 3.68%; P=0.009) were significantly higher in HF patients with CDI than without. Coexisting neurological disease (aOR: 3.74) and liver disease (aOR: 2.97) showed the strongest association as independent predictors of mortality. HF patients with CDI had longer hospital stays (14.45 ± 19.40 vs 5.44 ± 7.10 days; P<0.0001) and higher inflation-adjusted total hospital costs ($186,225 ± 376,485 vs $60,740 ± 153,992; P<0.001) compared to those without CDI.

CONCLUSION

The occurrence of concomitant CDI in patients admitted with acute HF exacerbation is associated with worse in-hospital outcomes and deaths as well as longer hospitalizations and greater financial cost.

Spironolactone and colitis: increased mortality in rodents and in humans

BACKGROUND

Crohn's disease causes intestinal inflammation leading to intestinal fibrosis. Spironolactone is an antifibrotic medication commonly used in heart failure to reduce mortality. We examined whether spironolactone is antifibrotic in the context of intestinal inflammation.

METHODS

In vitro, spironolactone repressed fibrogenesis in transforming growth factor beta (TGF-β)-stimulated human colonic myofibroblasts. However, spironolactone therapy significantly increased mortality in two rodent models of inflammation-induced intestinal fibrosis, suggesting spironolactone could be harmful during intestinal inflammation. Since inflammatory bowel disease (IBD) patients rarely receive spironolactone therapy, we examined whether spironolactone use was associated with mortality in a common cause of inflammatory colitis, Clostridium difficile infection (CDI).

RESULTS

Spironolactone use during CDI infection was associated with increased mortality in a retrospective cohort of 4008 inpatients (15.9% vs. 9.1%, n = 390 deaths, P < 0.0001). In patients without liver disease, the adjusted odds ratio (OR) for inpatient mortality associated with 80 mg spironolactone was 1.99 (95% confidence interval [CI]: 1.51-2.63) In contrast to the main effect of spironolactone mortality, multivariate modeling revealed a protective interaction between liver disease and spironolactone dose. The adjusted OR for mortality after CDI was 1.96 (95% CI: 1.50-2.55) for patients without liver disease on spironolactone vs. 1.28 (95% CI: 0.82-2.00) for patients with liver disease on spironolactone when compared to a reference group without liver disease or spironolactone use.

CONCLUSIONS

We propose that discontinuation of spironolactone in patients without liver disease during CDI could reduce hospital mortality by 2-fold, potentially reducing mortality from CDI by 35,000 patients annually across Europe and the U.S.

Treatment failure and recurrence of Clostridium difficile infection following treatment with vancomycin or metronidazole: a systematic review of the evidence

The objective of this review was to evaluate the frequency of treatment failure and recurrence of Clostridium difficile infection (CDI) following treatment with vancomycin or metronidazole in recently performed studies (last 10 years). Searches in PubMed and Scopus were performed by two reviewers independently. Data regarding treatment failure and recurrence following metronidazole and vancomycin treatment were extracted and analysed. In total, 39 articles (7005 patients) were selected for inclusion in the systematic review. The reported treatment failure was 22.4% with metronidazole (16 studies) and 14.2% with vancomycin (8 studies). Recurrence of CDI occurred in 27.1% of patients following metronidazole treatment (18 studies) and 24.0% of patients following vancomycin treatment (8 studies). Mean treatment failure and recurrence in the selected studies was 22.3% (24 studies) and 22.1% (37 studies). The reported outcomes depended on the study design (higher in prospective and retrospective cohort studies than in randomised controlled trials), geographic location of the study (higher in North America than in Europe and Asia), funding (higher in studies funded by non-profit organisations than pharmaceutical companies), mean age of the studied population (higher in older patients) and duration of follow-up (higher in studies with follow-up >1 month). In conclusion, infection with C. difficile is associated with 22.4% and 14.2% treatment failure and 27.1% and 24.0% recurrence after treatment with metronidazole and vancomycin, respectively. The variation in the reported outcomes amongst studies depends on the study design, location, funding, age and follow-up period.