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Carvalho FAC, Silva ROS, Santos BMRTD, Diniz AN, Vilela EG. CLINICAL OUTCOME AND SEVERITY OF CLOSTRIDIOIDES (CLOSTRIDIUM) DIFFICILE INFECTION AT A TERTIARY REFERRAL HOSPITAL IN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:330-338. [PMID: 37792762 DOI: 10.1590/s0004-2803.230302023-36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/21/2023] [Indexed: 10/06/2023]
Abstract
•The outcomes of CDI were evaluated in 65 patients with CDI in a Brazilian tertiary hospital. •Lack of clinical improvement after treatment and the severity score (ATLAS) increased the risk of death. •The use of multiple antimicrobial agents was associated with longer hospital stays. •Patients with high Charlson comorbidity index (>7) were more likely to recur. Background - Clostridioides difficile infection (CDI) is a potentially severe disease that can present with refractoriness, recurrence, and evolution to death. In Brazil, the epidemiology of CDI seems to differ from that of the United States and most European countries, with only one ribotype (RT) 027-related case and a high prevalence of RT106. Objective - The aim of this study was to evaluate the outcomes of CDI and its possible association with ribotypes at a university hospital in Brazil. Methods - A total of 65 patients with CDI were included and stool samples were submitted to A/B toxin detection and toxigenic culture, and toxigenic isolates (n=44) were also PCR ribotyped. Results - Patients' median age was 59 (20-87) years and there were 16 (24.6%) deaths. The median Charlson comorbidity index (CCI) was 4 (0-15) and 16.9% of the patients had CCI ≥8. The ATLAS score and non-improvement of diarrhea were related to higher mortality. A longer length of hospitalization was related to the enteral nutrition and use of multiple antibiotics. The period between CDI diagnosis and hospital discharge was longer in those who received new antibiotics after diagnosis, multiple antibiotics, and required intensive care treatment. Recurrence was associated with CCI >7. Twenty ribotypes were identified and RT106 was the most frequently detected strain (43.2%). No relationship was observed between the ribotypes and outcomes. CDI was present in patients with more comorbidities. Conclusion - Risk factors for higher mortality, longer hospital stay and recurrence were identified. A diversity of ribotypes was observed and C. difficile strains were not related to the outcomes.
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Affiliation(s)
| | | | | | - Amanda Nádia Diniz
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Eduardo Garcia Vilela
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Performance of Clostridioides difficile infection severity scores and risk factors related to 30-day all-cause mortality in patients with cancer. Support Care Cancer 2023; 31:187. [PMID: 36843052 DOI: 10.1007/s00520-023-07651-4] [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: 06/22/2022] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
PURPOSE There are currently no standard definitions for assessing the severity of Clostridioides difficile infection (CDI) in cancer patients. We evaluated the performance of scoring systems for severity and analyzed risk factors for mortality in a cancer cohort. METHODS We conducted an observational study in patients with cancer and CDI. We calculated the incidence of hospital-onset (HO-CDI) and community-onset health-care facility associated (CO-HCFA-CDI) episodes. We classified severity using five prognostic scales and calculated sensitivity, specificity, positive (PPV), and negative predictive values (NPV) for mortality and intensive care unit (ICU) admission. In addition, multivariate regression was performed to assess variables associated with mortality. RESULTS The HO-CDI and CO-HCFA-CDI incidence rates were 3.7 cases/10,000 patient-days and 1.9 cases/1,000 admissions, respectively. ESCMID criteria showed the higher sensitivity (97%, 95% CI; 85-100%) and NPV (98%, 95% CI; 85-100%), while ATLAS (≥ 6 points) had the highest specificity (95%, 95% CI; 90-98%) for 30-day all-cause mortality; similar performance was observed for ICU admission. Characteristics associated with fatal outcome were neutropenia (≤ 100 cells/ml) (aOR; 3.03, 95% CI; 1.05-8.74, p = 0.040), male gender (aOR; 2.90, 95% CI; 1.08-7.80, p = 0.034), high serum creatinine (aOR; 1.71, 95% CI; 1.09-2.70, p = 0.020), and albumin (aOR; 0.17, 95% CI; 0.07-0.42, p < 0.001). CONCLUSIONS Some of the current scales may not be appropriate to discriminate severity in patients with cancer. The variables in this study associated with unfavorable outcomes could be evaluated in prospective studies to develop prognostic scores that identify susceptible patients, especially in immunocompromised populations.
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Validation of Clinical Risk Models for Clostridioides difficile -Attributable Outcomes. Antimicrob Agents Chemother 2022; 66:e0067622. [PMID: 35727061 PMCID: PMC9295569 DOI: 10.1128/aac.00676-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Clostridioides difficile is the leading health care-associated pathogen, leading to substantial morbidity and mortality; however, there is no widely accepted model to predict C. difficile infection severity. Most currently available models perform poorly or were calibrated to predict outcomes that are not clinically relevant. We sought to validate six of the leading risk models (Age Treatment Leukocyte Albumin Serum Creatinine (ATLAS), C. difficile Disease (CDD), Zar, Hensgens, Shivashankar, and C. difficile Severity Score (CDSS)), guideline severity criteria, and PCR cycle threshold for predicting C. difficile-attributable severe outcomes (inpatient mortality, colectomy/ileostomy, or intensive care due to sepsis). Models were calculated using electronic data available within ±48 h of diagnosis (unavailable laboratory measurements assigned zero points), calibrated using a large retrospective cohort of 3,327 inpatient infections spanning 10 years, and compared using receiver operating characteristic (ROC) and precision-recall curves. ATLAS achieved the highest area under the ROC curve (AuROC) of 0.781, significantly better than the next best performing model (Zar 0.745; 95% confidence interval of AuROC difference 0.0094–0.6222; P = 0.008), and highest area under the precision-recall curve of 0.232. Current IDSA/SHEA severity criteria demonstrated moderate performance (AuROC 0.738) and PCR cycle threshold performed the worst (0.531). The overall predictive value for all models was low, with a maximum positive predictive value of 37.9% (ATLAS cutoff ≥9). No clinical model performed well on external validation, but ATLAS did outperform other models for predicting clinically relevant C. difficile-attributable outcomes at diagnosis. Novel markers should be pursued to augment or replace underperforming clinical-only models.
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Hung YP, Tsai CS, Tsai BY, Tsai PJ, Lee YT, Lee JC, Liu HC, Hsueh PR, Lee CC, Ko WC. Clostridioides difficile infection in patients with hematological malignancy: A multicenter study in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:1101-1110. [PMID: 33678554 DOI: 10.1016/j.jmii.2021.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/26/2021] [Accepted: 02/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Among the individuals with hematological malignancy (HM) complicated with Clostridioides difficile infection (CDI), the variables associated with in-hospital mortality and recurrence of CDI were investigated. MATERIAL AND METHODS Including adults with HM and those without malignancy suffering from CDI from January 2015 to December 2016 in three hospitals in Taiwan. RESULTS Totally 314 patients including 77 with HM and 237 patients without malignancy were included. HM patients more often had low leukocyte counts (<500 cells/mL: 28.6% vs. 2.1%) than those without malignancy and more patients without malignancy had severe CDI than patients with HM (31.6% vs. 14.3%, P = .003), according to the severity score of IDSA/SHEA. Patients with HM had a higher recurrence rate of CDI (14.3%, 11/77 vs. 7.2%, 17/237; P = .07) and longer hospital stay (47.2 ± 40.8 days vs. 33.3 ± 37.3 days; P = .006) than those without malignancy. In the multivariate analyses for those with HM and CDI, the in-hospital mortality was associated with vancomycin-resistant Enterococcus (VRE) colonization or infection (odds ratio [OR] 7.72; P = .01), and C. difficile ribotype 078 complex infection (OR 9.22; P = .03). Moreover underlying hematological malignancy (OR 2.74; P = .04) and VRE colonization/infection (OR 2.71; P = .02) were independently associated with CDI recurrence. CONCLUSION Patients with HM complicated with CDI were often regarded as non-severe infection, but had a similar in-hospital mortality rate as those without malignancy. CDI due to ribotype 078 complex isolates heralded a poor prognosis among HM patients.
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Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Shiang Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Bo-Yang Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Ti Lee
- Department of Internal Medicine and Division of Infectious Diseases, Chung Shan Medical University Hospital, and School of Medicine, Chung Shan Medical University Taichung, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Chuan Liu
- Department of Experiment and Diagnosis, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Kampouri E, Croxatto A, Prod’hom G, Guery B. Clostridioides difficile Infection, Still a Long Way to Go. J Clin Med 2021; 10:jcm10030389. [PMID: 33498428 PMCID: PMC7864166 DOI: 10.3390/jcm10030389] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/11/2022] Open
Abstract
Clostridioides difficile is an increasingly common pathogen both within and outside the hospital and is responsible for a large clinical spectrum from asymptomatic carriage to complicated infection associated with a high mortality. While diagnostic methods have considerably progressed over the years, the optimal diagnostic algorithm is still debated and there is no single diagnostic test that can be used as a standalone test. More importantly, the heterogeneity in diagnostic practices between centers along with the lack of robust surveillance systems in all countries and an important degree of underdiagnosis due to lack of clinical suspicion in the community, hinder a more accurate evaluation of the burden of disease. Our improved understanding of the physiopathology of CDI has allowed some significant progress in the treatment of CDI, including a broader use of fidaxomicine, the use of fecal microbiota transplantation for multiples recurrences and newer approaches including antibodies, vaccines and new molecules, already developed or in the pipeline. However, the management of CDI recurrences and severe infections remain challenging and the main question remains: how to best target these often expensive treatments to the right population. In this review we discuss current diagnostic approaches, treatment and potential prevention strategies, with a special focus on recent advances in the field as well as areas of uncertainty and unmet needs and how to address them.
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Affiliation(s)
- Eleftheria Kampouri
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
| | - Antony Croxatto
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Guy Prod’hom
- Institute of Microbiology, Department of Medical Laboratory and Pathology, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (A.C.); (G.P.)
| | - Benoit Guery
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, 1011 Lausanne, Switzerland;
- Correspondence: ; Tel.: +41-21-314-1643
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Jarmo O, Veli-Jukka A, Eero M. Treatment of Clostridioides (Clostridium) difficile infection. Ann Med 2020; 52:12-20. [PMID: 31801387 PMCID: PMC7877971 DOI: 10.1080/07853890.2019.1701703] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/29/2019] [Accepted: 11/24/2019] [Indexed: 02/06/2023] Open
Abstract
Clostridioides (formerly: Clostridium) difficile infection (CDI) is a major cause of diarrhoea for inpatients as well as outpatients. Usually, CDI is healthcare-associated but the number of community-acquired infections is increasing. CDI is generally associated with changes in the normal intestinal microbiota caused by administration of antibiotics. Elderly and immunocompromised patients are at greater risk for CDI and CDI recurrence. Recently, the treatment options of CDI have undergone major changes: current recommendations speak against using metronidazole for primary CDI, fidaxomicin and bezlotoxumab have been added to the treatment armamentarium and microbial replacement therapies have emerged. Several other therapies are undergoing clinical trials. In this article, we review current treatment guidelines, present the most recent data on the options to treat CDI and glance towards future developments.KEY MESSAGESThe cornerstones for the treatment of CDI are vancomycin and fidaxomicin. Metronidazole should be used only in mild-to-moderate disease in younger patients who have no or only few risk factors for recurrence.In recurrent CDI, bezlotoxumab infusion (a monoclonal antibody against C. difficile toxin B) may be considered as an adjunctive therapeutic strategy in addition to the standard care provided to patients with several risk factors for recurrence.Faecal microbiota transplantation (FMT) should be offered to patients with frequently recurring CDI.
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Affiliation(s)
- Oksi Jarmo
- Department of Infectious Diseases, Turku University Hospital, University of Turku, Turku, Finland
| | - Anttila Veli-Jukka
- Department of Infectious Diseases, Helsinki University Central Hospital, Helsinki, Finland
| | - Mattila Eero
- Department of Infectious Diseases, Helsinki University Central Hospital, Helsinki, Finland
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7
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Nana T, Moore C, Boyles T, Brink AJ, Cleghorn J, Devenish LM, du Toit B, Fredericks ES, Lekalakala-Mokaba MR, Maluleka C, Rajabally MN, Reubenson G, Shuping L, Swart K, Swe Han KS, Wadula J, Wojno J, Lowman W. South African Society of Clinical Microbiology Clostridioides difficile infection diagnosis, management and infection prevention and control guideline. S Afr J Infect Dis 2020; 35:219. [PMID: 34485483 PMCID: PMC8378053 DOI: 10.4102/sajid.v35i1.219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/24/2020] [Indexed: 12/17/2022] Open
Abstract
Clostridioides difficile infection (CDI) is a problem in both developed and developing countries and is a common hospital-acquired infection. This guideline provides evidence-based practical recommendations for South Africa and other developing countries. The scope of the guideline includes CDI diagnostic approaches; adult, paediatric and special populations treatment options; and surveillance and infection prevention and control recommendations.
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Affiliation(s)
- Trusha Nana
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Charlotte Maxeke Johannesburg Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Tom Boyles
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Adrian J. Brink
- Department of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Joy Cleghorn
- Life Healthcare Group, Johannesburg, South Africa
| | - Lesley M. Devenish
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Infection Control Services Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Ernst S. Fredericks
- Department of Physiology, Faculty of Science, Nelson Mandela University, Port Elizabeth, South Africa
| | - Molebogeng R. Lekalakala-Mokaba
- Department of Microbiology, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- Dr George Mukhari Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Pretoria, South Africa
| | - Caroline Maluleka
- Department of Microbiology, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- Dr George Mukhari Academic Hospital Microbiology Laboratory, National Health Laboratory Services, Pretoria, South Africa
| | | | - Gary Reubenson
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Liliwe Shuping
- Centre for Healthcare-Associated Infections, National Institute for Communicable Diseases, a division of National Health Laboratory Service, Johannesburg, South Africa
| | - Karin Swart
- Netcare Hospitals Limited, Johannesburg, South Africa
| | - Khine Swe Swe Han
- Medical Microbiology Department, Inkosi Albert Luthuli Central Hospital Academic Complex, National Health Laboratory Services, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Jeannette Wadula
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Chris Hani Baragwanath Hospital Microbiology Laboratory, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Warren Lowman
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Clinical Microbiology, PathCare/Vermaak Pathologists, Johannesburg, South Africa
- Department of Clinical Microbiology and Infection Prevention and Control, WITS Donald Gordon Medical Centre, Johannesburg, South Africa
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Oksi J, Aalto A, Säilä P, Partanen T, Anttila VJ, Mattila E. Real-world efficacy of bezlotoxumab for prevention of recurrent Clostridium difficile infection: a retrospective study of 46 patients in five university hospitals in Finland. Eur J Clin Microbiol Infect Dis 2019; 38:1947-1952. [PMID: 31359254 PMCID: PMC6778539 DOI: 10.1007/s10096-019-03630-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
Abstract
Reports on real-world experience on efficacy of bezlotoxumab (BEZ) has been lacking thus far. We retrospectively studied the efficacy and safety of BEZ in preventing the recurrence of Clostridium difficile infection (CDI) in five university hospitals in Finland. Seventy-three percent of our 46 patients remained free of recurrence in the following 3 months and the performance remained as 71% effective also among immunocompromised patients. In severe CDI, BEZ prevented recurrence in 63% of cases. From our study patients, 78% had three or more known risk factors for recurrence of CDI. Eight of our patients were waiting for fecal microbiota transplantation but after stopping the antibiotics that were continued to prevent recurrence of CDI and after receiving BEZ, all remained free of recurrence and did not need the procedure. Success with BEZ as an adjunctive treatment in preventing recurrence of CDI in high-risk patients may be rated as high. Among a subgroup of our patients, those already evaluated to be in need of fecal microbiota transplantation, BEZ seems to be an alternative option.
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Affiliation(s)
- Jarmo Oksi
- Department of Infectious Diseases, Turku University Hospital and Turku University, SH-rak 4.krs, PO Box 52, 20521, Turku, Finland.
| | - A Aalto
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - P Säilä
- Department of Infectious Diseases, Tampere University Hospital, Tampere, Finland
| | - T Partanen
- Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - V-J Anttila
- Department of Infectious Diseases, Helsinki University Central Hospital, Helsinki, Finland
| | - E Mattila
- Department of Infectious Diseases, Helsinki University Central Hospital, Helsinki, Finland
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9
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Misch EA, Safdar N. Clostridioides difficile Infection in the Stem Cell Transplant and Hematologic Malignancy Population. Infect Dis Clin North Am 2019; 33:447-466. [PMID: 31005136 PMCID: PMC6790983 DOI: 10.1016/j.idc.2019.02.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Clostridioides difficile infection (CDI) is common in the stem cell transplant (SCT) and hematologic malignancy (HM) population and mostly occurs in the early posttransplant period. Treatment of CDI in SCT/HM is the same as for the general population, with the exception that fecal microbiota transplant (FMT) has not been widely adopted because of safety concerns. Several case reports, small series, and retrospective studies have shown that FMT is effective and safe. A randomized controlled trial of FMT for prophylaxis of CDI in SCT patients is underway. In addition, an abundance of novel therapeutics for CDI is currently in development.
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Affiliation(s)
- Elizabeth Ann Misch
- Department of Medicine, Division of Infectious Disease, University of Wisconsin School of Medicine & Public Health, 1685 Highland Drive, Centennial Building, 5th Floor, Madison, WI 53705, USA.
| | - Nasia Safdar
- Department of Medicine, Division of Infectious Disease, University of Wisconsin School of Medicine & Public Health, 1685 Highland Drive, Centennial Building, 5th Floor, Madison, WI 53705, USA; Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, WI 53705, USA
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10
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Abughanimeh O, Qasrawi A, Kaddourah O, Al Momani L, Abu Ghanimeh M. Clostridium difficile infection in oncology patients: epidemiology, pathophysiology, risk factors, diagnosis, and treatment. Hosp Pract (1995) 2018; 46:266-277. [PMID: 30296190 DOI: 10.1080/21548331.2018.1533673] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection (CDI) is one of the most common healthcare-associated infections in the United States. Its incidence has been increasing in the recent years despite preventative measures. CDI increases annual expenses by 1.5 billion dollars. Cancer patients are at higher risk to acquire CDI, as explained by their frequent exposure to risk factors. CDI in cancer patients is associated with higher mortality rates and prolonged hospitalization. Furthermore, CDI affects the course of the disease by delaying treatments such as chemotherapy. Chemotherapeutics drugs are considered independent risk factors for CDI. This review discusses Clostridium difficile infection in cancer patients, including those who are receiving chemotherapy. Herein, we summarize recent data regarding the epidemiology, risk factors, including chemotherapy regimens, pathogenesis, diagnostic techniques and treatment options, including newer agents. Method: A literature search was performed using the PubMed and Google Scholar databases. The MeSH terms utilized in different combinations were 'clostridium difficile', 'neoplasia/cancer/oncology', 'chemotherapy', 'diagnosis', and 'treatment', in addition to looking up each treatment option individually to generate a comprehensive search. The articles were initially screened by title alone, followed by screening through abstracts. Full texts of pertinent articles (including letters to editors, case reports, case series, cohort studies, and clinical trials) were included in this review.
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Affiliation(s)
- Omar Abughanimeh
- a School of Medicine Internal Medicine , University of Missouri , Kansas City , USA
| | - Ayman Qasrawi
- a School of Medicine Internal Medicine , University of Missouri , Kansas City , USA
| | - Osama Kaddourah
- a School of Medicine Internal Medicine , University of Missouri , Kansas City , USA
| | - Laith Al Momani
- b East Tennessee State University James H Quillen College of Medicine - Internal Medicine , USA
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66:e1-e48. [PMID: 29462280 PMCID: PMC6018983 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1266] [Impact Index Per Article: 211.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines
- Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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12
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Robin C, Héquette-Ruz R, Guery B, Boyle E, Herbaux C, Galperine T. Treating Clostridium difficile infection in patients presenting with hematological malignancies: Are current guidelines applicable? Med Mal Infect 2017; 47:532-539. [PMID: 28823390 DOI: 10.1016/j.medmal.2017.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/15/2016] [Accepted: 07/10/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Adults with hematological malignancies are at high-risk of Clostridium difficile infection (CDI), but no guidelines for CDI treatment are available in this population. Our primary objective was to evaluate the clinical outcomes in CDI patients with hematological malignancies. Our secondary objectives were to describe CDI severity using the main clinical guidelines and to evaluate the compliance of treatment choice with published guidelines. PATIENTS AND METHODS Single-center, retrospective, observational case series including every consecutive adult patient with a confirmed diagnosis of CDI admitted in the hematology unit of our teaching hospital. Each CDI episode was classified as moderate, severe, or complicated according to the main clinical guidelines (IDSA 2010, AJG 2013, ESCMID 2014). RESULTS Twenty-three episodes of CDI in 19 patients admitted to the hematology unit occurred between June 2012 and October 2013. Clinical cure was achieved for 20 episodes (87%). Ten weeks after diagnosis, global cure was reached for 14 episodes (61%) whereas recurrence occurred in two episodes (10%). The mortality rate reached 37% (7/19) but the attributable mortality rate was 5% (1/19). ESCMID criteria more frequently classified patients in the severe category compared with the two other classifications. Prescription compliance with clinical guidelines was observed in 61% of episodes with IDSA criteria, 43% with AJG, and 9% with ESCMID. CONCLUSIONS IDSA and AJG assessment may underestimate the potential risk of unfavorable clinical outcome. Further prospective studies on a larger cohort are needed to develop adequate treatment guidelines for CDI in hematology settings.
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Affiliation(s)
- C Robin
- Department of Hematology, Henri-Mondor Teaching Hospital, University Paris-Est Créteil (UPEC), Assistance publique-Hôpitaux de Paris (AP-HP), 94000 Créteil, France; University Paris-Est Créteil (UPEC), 94000 Créteil, France
| | - R Héquette-Ruz
- Department of Infectious Diseases, CHU de Lille, 59000 Lille, France
| | - B Guery
- Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - E Boyle
- Department of Hematology, CHU de Lille, 59000 Lille, France
| | - C Herbaux
- Department of Hematology, CHU de Lille, 59000 Lille, France
| | - T Galperine
- Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.
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Delgado A, Reveles IA, Cabello FT, Reveles KR. Poorer outcomes among cancer patients diagnosed with Clostridium difficile infections in United States community hospitals. BMC Infect Dis 2017. [PMID: 28645266 PMCID: PMC5481960 DOI: 10.1186/s12879-017-2553-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Cancer predisposes patients to Clostridium difficile infection (CDI) due to health care exposures and medications that disrupt the gut microbiota or reduce immune response. Despite this association, the national rate of CDI among cancer patients is unknown. Furthermore, it is unclear how CDI affects clinical outcomes in cancer. The objective of this study was to describe CDI incidence and health outcomes nationally among cancer patients in the United States (U.S.). Methods Data for this study were obtained from the U.S. National Hospital Discharge Surveys from 2001 to 2010. Eligible patients included those at least 18 years old with a discharge diagnosis of cancer (ICD-9-CM codes 140–165.X, 170–176.X, 179–189.X, 190–209.XX). CDI was identified using ICD-9-CM code 008.45. Data weights were applied to sampled patients to provide national estimates. CDI incidence was calculated as CDI discharges per 1000 total cancer discharges. The in-hospital mortality rate and hospital length of stay (LOS) were compared between cancer patients with and without CDI using bivariable analyses. Results A total of 30,244,426 cancer discharges were included for analysis. The overall incidence of CDI was 8.6 per 1000 cancer discharges. CDI incidence increased over the study period, peaking in 2008 (17.2 per 1000 cancer discharges). Compared to patients without CDI, patients with CDI had significantly higher mortality (9.4% vs. 7.5%, p < 0.0001) and longer median LOS (9 days vs. 4 days, p < 0.0001). Conclusions CDI incidence is increasing nationally among cancer patients admitted to U.S. community hospitals. CDI was associated with significantly increased mortality and hospital LOS.
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Affiliation(s)
- Andrew Delgado
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1900, Austin, TX, 78712, USA.,Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA
| | - Ivan A Reveles
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1900, Austin, TX, 78712, USA.,Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA.,Cancer Therapy and Research Center, The University of Texas Health Science Center at San Antonio, 7979 Wurzbach Road, San Antonio, TX, 78229, USA
| | - Felicia T Cabello
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1900, Austin, TX, 78712, USA.,Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA
| | - Kelly R Reveles
- College of Pharmacy, The University of Texas at Austin, 2409 University Avenue, A1900, Austin, TX, 78712, USA. .,Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC-6220, San Antonio, TX, 78229, USA.
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14
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Scardina TL, Kang Martinez E, Balasubramanian N, Fox-Geiman M, Smith SE, Parada JP. Evaluation of Risk Factors for Clostridium difficile Infection in Hematopoietic Stem Cell Transplant Recipients. Pharmacotherapy 2017; 37:420-428. [PMID: 28226419 DOI: 10.1002/phar.1914] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVES The primary objective was to determine the impact of hematologic malignancies and/or conditioning regimens on the risk of developing Clostridium difficile infection (CDI) in patients undergoing hematopoietic stem cell transplantation (HSCT). Secondary objectives were to determine if traditional CDI risk factors applied to patients undergoing HSCT and to determine the presence of CDI markers of severity of illness among this patient population. DESIGN Single-center retrospective case-control study. SETTING Quaternary care academic medical center. PATIENTS A total of 105 patients who underwent HSCT between December 2009 and December 2014; of these patients, 35 developed an initial episode of CDI (HSCT/CDI group [cases]), and 70 did not (controls). Controls were matched in a 2:1 ratio to cases based on age (± 10 yrs) and date of HSCT (± 6 mo). MEASUREMENTS AND MAIN RESULTS Baseline characteristics of the two groups were well balanced regarding age, sex, race, ethnicity, and type of HSCT. No significant differences in conditioning regimen, hematologic malignancy, total body irradiation received for HSCT, use of antibiotics within 60 days of HSCT, or use of prophylactic antibiotics after HSCT were noted between the two groups. Patients in the control group were 10.57 (95% confidence interval 1.24-492.75) more likely to have received corticosteroids prior to HSCT than patients in the HSCT/CDI group (p=0.01). Use of proton pump inhibitors at the time of HSCT was greater among the control group than among patients in the HSCT/CDI group (97% vs 86%, p=0.048). No significant difference in mortality was noted between the groups at 3, 6, and 12 months after HSCT. Metronidazole was frequently prescribed for patients in the HSCT/CDI group (34 patients [97%]). Severe CDI was not common among patients within the HSCT/CDI group (13 patients [37%]); vancomycin was infrequently prescribed for these patients ([31%] 4/13 patients). CONCLUSION Hematologic malignancies and a conditioning regimen administered for HSCT were not significant risk factors for the development of CDI after HSCT. Use of corticosteroids prior to HSCT and use of proton pump inhibitors at the time of HSCT were associated with a significantly decreased risk of CDI.
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Affiliation(s)
- Tonya L Scardina
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois
| | | | | | - Mary Fox-Geiman
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois
| | - Scott E Smith
- Division of Hematology/Oncology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Jorge P Parada
- Division of Infectious Diseases, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
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15
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Neemann K, Freifeld A. Clostridium difficile–Associated Diarrhea in the Oncology Patient. J Oncol Pract 2017; 13:25-30. [DOI: 10.1200/jop.2016.018614] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile is the most common cause of nosocomial diarrhea, resulting in significant morbidity and mortality in hospitalized patients. Oncology patients are particularly at risk of this infection secondary to frequent exposure to known risk factors. In a population in which diarrhea is a common adverse effect of chemotherapeutic regimens, diagnosis can be challenging secondary to current limitations in testing to differentiate between colonization and active infection. Although several currently available antimicrobial therapies achieve resolution of symptoms in this population, further research is needed to determine which agent least affects the host intestinal microbiota, especially in times of neutropenia and mucosal barrier injury. The purpose of this article is to review the current literature on the epidemiology, pathogenesis, and management of C difficile–associated diarrhea in the oncology population.
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Affiliation(s)
- Kari Neemann
- University of Nebraska Medical Center, Omaha, NE
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16
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Hebbard AIT, Slavin MA, Reed C, Teh BW, Thursky KA, Trubiano JA, Worth LJ. The epidemiology of Clostridium difficile infection in patients with cancer. Expert Rev Anti Infect Ther 2016; 14:1077-1085. [PMID: 27606976 DOI: 10.1080/14787210.2016.1234376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Clostridium difficile infection (CDI) is a significant cause of healthcare-associated diarrhoea, and the emergence of endemic strains resulting in poorer outcomes is recognised worldwide. Patients with cancer are a specific high-risk group for development of infection. Areas covered: In this review, modifiable and non-modifiable risk factors for CDI in adult patients with haematological malignancy or solid tumours are evaluated. In particular, the contribution of antimicrobial exposure, hospitalisation and gastric acid suppression to risk of CDI are discussed. Recent advances in CDI treatment are outlined, namely faecal microbiota transplantation and fidaxomicin therapy for severe/refractory infection in cancer populations. Outcomes of CDI, including mortality are presented, together with the need for valid severity rating tools customised for cancer populations. Expert commentary: Future areas for research include the prognostic value of C. difficile colonisation in cancer patients and the potential impact of dedicated antimicrobial stewardship programs in reducing the burden of CDI in cancer units.
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Affiliation(s)
- Andrew I T Hebbard
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia
| | - Caroline Reed
- c Microbiology Department , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Benjamin W Teh
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Karin A Thursky
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Jason A Trubiano
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Leon J Worth
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia.,d Victorian Healthcare Associated Infection Surveillance System (VICNISS) , Doherty Institute , Melbourne , Australia
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17
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Cózar-Llistó A, Ramos-Martinez A, Cobo J. Clostridium difficile Infection in Special High-Risk Populations. Infect Dis Ther 2016; 5:253-69. [PMID: 27515721 PMCID: PMC5019980 DOI: 10.1007/s40121-016-0124-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Indexed: 02/07/2023] Open
Abstract
Antibiotic use continues to be the most important risk factor for the development of Clostridium difficile infection (CDI) through disruption of the indigenous microbiota of the colon. This factor, together with environmental contamination, makes hospital and other healthcare facilities the perfect breeding ground for the infection. Several groups of patients are exposed to the hospital environment and, at the same time, affected by conditions that can make CDI more prevalent, more severe or make it present a different clinical picture. The list of such conditions appears too extensive to be reviewed in a single article. Nevertheless, several groups, including the critically ill, oncological patients, solid organ and hematopoietic transplant recipients, patients with inflammatory bowel disease, patients with kidney disease and pregnant women, have generated more attention and have been studied in more detail. On the other hand, pediatric patients constitute a controversial group because the large number of asymptomatic carriers makes interpretation of clinical findings and diagnostic tests difficult, as is the development of an appropriate approach to treatment. We present an in-depth discussion of CDI in these high-risk populations and we also review the issue of CDI in pediatric patients.
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Affiliation(s)
- Alberto Cózar-Llistó
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Antonio Ramos-Martinez
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Javier Cobo
- Infectious Diseases Service, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Viejo Km 9.1, 28034, Madrid, Spain.
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Kociolek LK, Patel SJ, Shulman ST, Gerding DN. Concomitant Medical Conditions and Therapies Preclude Accurate Classification of Children With Severe or Severe Complicated Clostridium difficile Infection. J Pediatric Infect Dis Soc 2015; 4:e139-42. [PMID: 26582882 DOI: 10.1093/jpids/piu121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 11/30/2014] [Indexed: 12/29/2022]
Abstract
Severe and severe complicated Clostridium difficile infections (SCDI/SCCDI) were retrospectively assessed in a pediatric cohort. Underlying medical conditions and concomitant medical therapy preclude accurate classification of children with SCDI/SCCDI, using current CDI severity definitions. Revised CDI definitions in children should focus on more objective, age-appropriate, and CDI-specific markers of severity.
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Affiliation(s)
- Larry K Kociolek
- Department of Pediatrics, Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sameer J Patel
- Department of Pediatrics, Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stanford T Shulman
- Department of Pediatrics, Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dale N Gerding
- Department of Medicine, Edward Hines, Jr. VA Hospital, Hines, Illinois Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
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19
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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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20
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21
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Abstract
BACKGROUND Clostridium difficile infection (CDI) is an increasingly important cause of morbidity in hospitalized children. We describe the recent epidemiology of pediatric CDI at a children's hospital, compare community-associated (CA) and hospital-associated (HA) infections and identify risk factors for severe disease. METHODS Children with CDI at Texas Children's Hospital were identified from February 1, 2011, to October 31, 2011. Severe CDI was defined as the presence of a CDI-related complication or ≥2 clinical features: fever, bloody stools, leukocytosis, hypoalbuminemia or elevated creatinine. Standard epidemiologic definitions were used. RESULTS One-hundred and nine unique patients 1-21 years of age with CDI were identified throughout the study period. The proportions of CA-CDI (41%) and HA-CDI (46%) were similar, whereas community-onset indeterminate CDI (13%) was less common. Children with malignancy or solid organ transplantation were more likely to have HA-CDI. Conversely, all children with inflammatory bowel disease had CA-CDI. Twenty-three patients (21%) met criteria for severe disease and 8 experienced a CDI-related complication, including 1 death attributable to CDI. On multivariate analysis, the presence of a gastrostomy tube (adjusted odds ratio: 3.09; 95% confidence interval: 1.07-8.94) and having community-onset indeterminate disease (adjusted odds ratio: 4.62; 95% confidence interval: 1.28-16.67) were found to be associated with severe CDI. CONCLUSIONS A substantial proportion of pediatric CDI is CA and there are clinical differences between children with CA-CDI and HA-CDI. Children with CDI frequently experience severe disease, whereas complications are uncommon. Early identification and treatment of CDI should be pursued in children with gastrostomy tube and recent hospitalization.
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22
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Gweon TG, Choi MG, Baeg MK, Lim CH, Park JM, Lee IS, Kim SW, Lee DG, Park YJ, Lee JW. Hematologic diseases: High risk of Clostridium difficile associated diarrhea. World J Gastroenterol 2014; 20:6602-6607. [PMID: 24914383 PMCID: PMC4047347 DOI: 10.3748/wjg.v20.i21.6602] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 01/30/2014] [Accepted: 03/10/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the incidence and clinical outcome of Clostridium difficile (C. difficile) associated diarrhea (CDAD) in patients with hematologic disease.
METHODS: We retrospectively reviewed the medical records of patients who underwent C. difficile testing in a tertiary hospital in 2011. The incidence and risk factors for CDAD and its clinical course including recurrence and mortality were assessed in patients with hematologic disease and compared with those in patients with nonhematologic disease.
RESULTS: About 320 patients were diagnosed with CDAD (144 patients with hematologic disease; 176 with nonhematologic disease). The incidence of CDAD in patients with hematologic disease was estimated to be 36.7 cases/10000 patient hospital days, which was higher than the 5.4 cases/10000 patient hospital days in patients with nonhematologic disease. Recurrence of CDAD was more frequent in patients with hematologic disease compared to those with nonhematologic disease (18.8% vs 8.5%, P < 0.01), which was associated with higher re-use of causative antibiotics for CDAD. Mortality due to CDAD did not differ between the two groups. Multivariate analysis showed that intravenous immunoglobulin was the only significant factor associated with a lower rate of recurrence of CDAD in patients with hematologic disease.
CONCLUSION: The incidence and recurrence of CDAD was higher in patients with hematologic disease than in those with nonhematologic disease.
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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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Cowan AJ, Altemeier WA, Johnston C, Gernsheimer T, Becker PS. Management of Acute Myeloid Leukemia in the Intensive Care Setting. J Intensive Care Med 2014; 30:375-84. [DOI: 10.1177/0885066614530959] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 12/16/2013] [Indexed: 01/18/2023]
Abstract
Patients with acute myeloid leukemia (AML) who are newly diagnosed or relapsed and those who are receiving cytotoxic chemotherapy are predisposed to conditions such as sepsis due to bacterial and fungal infections, coagulopathies, hemorrhage, metabolic abnormalities, and respiratory and renal failure. These conditions are common reasons for patients with AML to be managed in the intensive care unit (ICU). For patients with AML in the ICU, providers need to be aware of common problems and how to manage them. Understanding the pathophysiology of complications and the recent advances in risk stratification as well as newer therapy for AML are relevant to the critical care provider.
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Affiliation(s)
- Andrew J. Cowan
- Division of Hematology, University of Washington, Seattle, WA, USA
- Division of Medical Oncology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
| | - William A. Altemeier
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| | - Christine Johnston
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Terry Gernsheimer
- Division of Hematology, University of Washington, Seattle, WA, USA
- Puget Sound Blood Center, Seattle, WA, USA
| | - Pamela S. Becker
- Division of Hematology, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, USA
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Yoon YK, Kim MJ, Sohn JW, Kim HS, Choi YJ, Kim JS, Kim ST, Park KH, Kim SJ, Kim BS, Shin SW, Kim YH, Park Y. Predictors of mortality attributable to Clostridium difficile infection in patients with underlying malignancy. Support Care Cancer 2014; 22:2039-48. [PMID: 24595407 DOI: 10.1007/s00520-014-2174-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE This study aimed at evaluating the clinical severity and treatment outcomes of Clostridium difficile infections (CDI) and identifying predictors associated with mortality in patients with malignancy. METHODS A retrospective study was conducted in a teaching hospital from January 2004 to June 2013. The subjects included adult patients (aged ≥ 18 years) receiving treatment for malignancy whose conditions were complicated by CDI. Clinical severity was determined using the guidelines from the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America (SHEA/IDSA). Multivariate logistic regression analysis was performed to identify predictors independently associated with CDI-related mortality. RESULTS Of the 5,594 patients treated for malignancy at the Division of Hematology/Oncology during the study period, 61 (1.1%) had CDI complications. CDI-related mortality was 19.7% (12/61). Twenty-seven (44.3%) patients were diagnosed with neutropenia (ANC ≤ 500/mm(3)) at initial CDI presentation. Forty-one patients (67.2%) received antimicrobial therapy for CDI. Based on the SHEA/IDSA guidelines, only 12 patients (19.7%) presented with severe CDI, but 25 (61.0%) patients experienced treatment failure. Multiple logistic regression modeling showed neutropenia to be an independent risk factor for CDI-related mortality (odds ratio, 5.17; 95% confidence interval, 1.24-21.59). CONCLUSIONS This study tracked poor CDI treatment outcomes in patients with malignancy and identified neutropenia as a previously unrecognized risk factor of CDI-related mortality. Alternative definitions of severe CDI that include neutropenia might be necessary to more accurately determine clinical severity.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
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Abstract
Cancer patients, particularly those with neutropenia, are at risk for enteric and intra-abdominal infections. Specific infections and infectious syndromes in this setting include neutropenic enterocolitis, bacterial infections such as Clostridium difficile infection (CDI), viral infections such as CMV colitis, and parasitic infections such as strongyloidiasis. Diagnosing and gauging the severity of CDI presents challenges, as chemotherapy may produce symptoms that mimic CDI and laboratory findings such as leukocytosis are not reliable in this population. Treatment for enteric infections should be pathogen specific, although broad-spectrum antibiotics are often required as initial empiric therapy in patients with neutropenia.
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Affiliation(s)
- Michael Wang
- Division of Infectious Diseases, Lakeland Regional Medical Center, 1234 Napier Avenue, St. Joseph, MI, 49085, USA,
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Green MR, Acharya UH, Yeager AM. Is Fidaxomicin the Drug of Choice for Treating Clostridium difficile–Associated Diarrhea in Patients With Cancer? J Clin Oncol 2013; 31:4376-8. [DOI: 10.1200/jco.2013.52.8513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Clostridium difficile infection among hematopoietic stem cell transplant recipients: beyond colitis. Curr Opin Infect Dis 2013; 26:326-31. [PMID: 23806895 DOI: 10.1097/qco.0b013e3283630c4c] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review the most recent data regarding the epidemiology, risks factors, and outcomes among hematopoietic stem cell transplant recipients with Clostridium difficile infection (CDI). RECENT FINDINGS With the emergence of an epidemic strain of C. difficile known as NAP1 in the early 2000s, rates of this infection have escalated globally. Hematopoietic stem cell transplant recipients appear to be one of the most vulnerable populations for the development of CDI. Traditional risk factors for CDI including antimicrobial exposure and older age are likely only a piece of the overall risk profile, with recent study results also emphasizing other factors such as transplant type, conditioning regimen, and graft-versus-host disease (GVHD). The relationship between CDI and subsequent development of GVHD, particularly of the gastrointestinal tract, is of specific interest. A bidirectional relationship of association has been highlighted in a number of recent studies and underscores the need for further prospective studies to address the potential indirect effects of alloreactivity induced by CDI. SUMMARY CDI has emerged as one of the most common infections in the early transplant period. Recent studies have begun to address the epidemiology of disease, risk factors for, and outcomes after infection in the stem cell transplant. However, more research is needed to unravel the observed relationship between CDI and GVHD.
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