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Eeuwijk J, Ferreira G, Yarzabal JP, Robert-Du Ry van Beest Holle M. A Systematic Literature Review on Risk Factors for and Timing of Clostridioides difficile Infection in the United States. Infect Dis Ther 2024; 13:273-298. [PMID: 38349594 PMCID: PMC10904710 DOI: 10.1007/s40121-024-00919-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/10/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is a major public health threat. Up to 40% of patients with CDI experience recurrent CDI (rCDI), which is associated with increased morbidity. This study aimed to define an at-risk population by obtaining a detailed understanding of the different factors leading to CDI, rCDI, and CDI-related morbidity and of time to CDI. METHODS We conducted a systematic literature review (SLR) of MEDLINE (using PubMed) and EMBASE for relevant articles published between January 1, 2016, and November 11, 2022, covering the US population. RESULTS Of the 1324 articles identified, 151 met prespecified inclusion criteria. Advanced patient age was a likely risk factor for primary CDI within a general population, with significant risk estimates identified in nine of 10 studies. Older age was less important in specific populations with comorbidities usually diagnosed at earlier age, such as bowel disease and cancer. In terms of comorbidities, the established factors of infection, kidney disease, liver disease, cardiovascular disease, and bowel disease along with several new factors (including anemia, fluid and electrolyte disorders, and coagulation disorders) were likely risk factors for primary CDI. Data on diabetes, cancer, and obesity were mixed. Other primary CDI risk factors were antibiotics, proton pump inhibitors, female sex, prior hospitalization, and the length of stay in hospital. Similar factors were identified for rCDI, but evidence was limited. Older age was a likely risk factor for mortality. Timing of primary CDI varied depending on the population: 2-3 weeks in patients receiving stem cell transplants, within 3 weeks for patients undergoing surgery, and generally more than 3 weeks following solid organ transplant. CONCLUSION This SLR uses recent evidence to define the most important factors associated with CDI, confirming those that are well established and highlighting new ones that could help to identify patient populations at high risk.
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Affiliation(s)
- Jennifer Eeuwijk
- Pallas Health Research and Consultancy, a P95 Company, Rotterdam, Netherlands
| | | | - Juan Pablo Yarzabal
- GSK, Wavre, Belgium.
- GSK, B43, Rue de l'Institut, 89, 1330, Rixensart, Belgium.
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Laeeq T, Tun KM, Vongsavath T, Singh A, Manne V. Incidence and risk factors of Clostridioides difficile infection in liver transplant recipients: A comprehensive literature review. Clin Liver Dis (Hoboken) 2024; 23:e0131. [PMID: 38487351 PMCID: PMC10939552 DOI: 10.1097/cld.0000000000000131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/26/2023] [Indexed: 03/17/2024] Open
Affiliation(s)
- Tooba Laeeq
- Department of Internal Medicine, University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Kyaw Min Tun
- Department of Internal Medicine, University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Tahne Vongsavath
- Department of Internal Medicine, University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Aditi Singh
- Department of Internal Medicine, University of Nevada, Las Vegas, Las Vegas, Nevada, USA
| | - Vignan Manne
- Department of Gastroenterology, University of Nevada, Las Vegas, Las Vegas, Nevada, USA
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Muñoz Cuevas C, Asencio Egea MÁ, Franco Huerta M, Huertas Vaquero M, Arias Arias Á, Carranza González R. Case-control study of Clostridioides difficile in a rural health care area. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:1-9. [PMID: 35104606 DOI: 10.1016/j.gastrohep.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 12/12/2021] [Accepted: 01/20/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To determine the risk and prognostic factors for Clostridioides difficile infection (CDI). PATIENTS AND METHODS Prospective, case-control study with 61 cases and 64 controls, aged ≥2 years with diarrhoea, carried out in Castilla-La Mancha Health Care Area for 14 months. The diagnosis was made by immunochromatography technics (glutamate dehydrogenase and toxin A/B), confirming discordant cases by isothermal amplification. Demographic variables, comorbidities, type of acquisition, previous administration of antibiotics, antacids and immunosuppressants, and evolution were collected. The data were analysed using the chi-square test and the effect of risk and prognostic factors was quantified using an odds ratio with 95% confidence intervals. RESULTS Hospital admission 4 weeks prior to infection, hypoalbuminemia, and previous administration of antibiotics were identified as independent risk factors for CDI. Presenting these 3 factors constitutes nearly 3-fold increase in the risk of becoming infected. A greater number of hospital admissions in the 4-12 weeks prior to CDI were found in the group of nosocomial acquisition. Although there was a greater tendency to recurrence and an unfavourable prognosis among nosocomial cases, these differences were not significant. We found that fever and hospital admission in the 4 weeks prior to infection were unfavourable prognostic factors of CDI. CONCLUSIONS The independent risk factors for CDI were: Hospital admission in the 4 weeks prior to infection, hypoalbuminemia, and previous administration of antibiotics. Fever and hospitalisation in the previous 4 weeks were also identified as prognostic factors of unfavourable evolution.
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Affiliation(s)
- Cristina Muñoz Cuevas
- Laboratorio de Microbiología, Hospital General La Mancha Centro, Ciudad Real, España
| | | | - María Franco Huerta
- Servicio de Medicina Interna, Hospital General La Mancha Centro, Ciudad Real, España
| | - María Huertas Vaquero
- Laboratorio de Microbiología, Hospital General La Mancha Centro, Ciudad Real, España
| | - Ángel Arias Arias
- Unidad de Apoyo a la Investigación, Hospital General La Mancha Centro, Ciudad Real, España
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Kunishima H, Ohge H, Suzuki H, Nakamura A, Matsumoto K, Mikamo H, Mori N, Morinaga Y, Yanagihara K, Yamagishi Y, Yoshizawa S. Japanese Clinical Practice Guidelines for Management of Clostridioides (Clostridium) difficile infection. J Infect Chemother 2022; 28:1045-1083. [PMID: 35618618 DOI: 10.1016/j.jiac.2021.12.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/16/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Hiroyuki Kunishima
- Department of Infectious Diseases, St. Marianna University School of Medicine, Japan.
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Hiromichi Suzuki
- Division of Infectious Diseases, Department of Medicine, Tsukuba Medical Center Hospital, Japan
| | - Atsushi Nakamura
- Division of Infection Control and Prevention, Nagoya City University Hospital, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Japan
| | - Hiroshige Mikamo
- Clinical Infectious Diseases, Graduate School of Medicine, Aichi Medical University, Japan
| | - Nobuaki Mori
- Division of General Internal Medicine and Infectious Diseases, National Hospital Organization Tokyo Medical Center, Japan
| | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Yuka Yamagishi
- Clinical Infectious Diseases, Graduate School of Medicine, Aichi Medical University, Japan
| | - Sadako Yoshizawa
- Department of Clinical Laboratory/Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Japan
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Clostridioides difficile Infection in Liver Cirrhosis: A Concise Review. Can J Gastroenterol Hepatol 2022; 2022:4209442. [PMID: 35711246 PMCID: PMC9197604 DOI: 10.1155/2022/4209442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/04/2022] [Accepted: 05/24/2022] [Indexed: 12/16/2022] Open
Abstract
Clostridium difficile is a Gram-positive bacillus with fecal-oral transmission and is currently one of the most common nosocomial infections worldwide, which was renamed Clostridioides difficile in 2016. Clostridioides difficile infection (CDI) is a prevalent infection in cirrhosis and negatively affects prognosis. This study aimed to provide a concise review with clinical practice implications. The prevalence of CDI in cirrhotic patients increases, while the associated mortality decreases. Multiple groups of risk factors increase the likelihood of CDI in patients with cirrhosis, such as antibiotic use, the severity of cirrhosis, some comorbidities, and demographic aspects. Treatment in the general population is currently described in the latest guidelines. In patients with cirrhosis, rifaximin and lactulose have been shown to reduce CDI risk due to their modulatory effects on the intestinal flora, although conflicting results exist. Fecal microbiota transplantation (FMT) as a treatment for the second or subsequent CDI recurrences has demonstrated a good safety and efficacy in cirrhosis and CDI. Future validation in more prospective studies is needed. Screening of asymptomatic patients appears to be discouraged for the prevention currently, with strict hand hygiene and cleaning of the ward and medical equipment surfaces being the cornerstone of minimizing transmission.
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Sahra S, Abureesh M, Amarnath S, Alkhayyat M, Badran R, Jahangir A, Gumaste V. Clostridioides difficile infection in liver cirrhosis patients: A population-based study in United States. World J Hepatol 2021; 13:926-938. [PMID: 34552699 PMCID: PMC8422922 DOI: 10.4254/wjh.v13.i8.926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/11/2021] [Accepted: 07/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridioides (formerly Clostridium) difficile infection (CDI) is an increasingly frequent cause of morbidity and mortality in hospitalized patients. Multiple risk factors are documented in the literature that includes, but are not limited to, antibiotics use, advanced age, and gastric acid suppression. Several epidemiological studies have reported an increased incidence of CDI in advanced liver disease patients. Some have also demonstrated a higher prevalence of nosocomial infections in cirrhotic patients.
AIM To use a large nationwide database, we sought to determine CDI’s risk among liver cirrhosis patients in the United States.
METHODS We queried a commercial database (Explorys IncTM, Cleveland, OH, United States), and obtained an aggregate of electronic health record data from 26 major integrated United States healthcare systems comprising 360 hospitals in the United States from 2018 to 2021. Diagnoses were organized into the Systematized Nomenclature of Medicine Clinical Terms (SNOMED–CT) hierarchy. Statistical analysis for the multivariable model was performed using Statistical Package for Social Sciences (SPSS version 25, IBM CorpTM). For all analyses, a two-sided P value of < 0.05 was considered statistically significant.
RESULTS There were a total of 19387760 patients in the database who were above 20 years of age between the years 2018-2021. Of those, 133400 were diagnosed with liver cirrhosis. The prevalence of CDI amongst the liver cirrhosis population was 134.93 per 100.000 vs 19.06 per 100.000 in non-cirrhotic patients (P < 0.0001). The multivariate analysis model uncovered that cirrhotic patients were more likely to develop CDI (OR: 1.857; 95%CI: 1.665-2.113, P < 0.0001) compared to those without any prior history of liver cirrhosis.
CONCLUSION In this large database study, we uncovered that cirrhotic patients have a significantly higher CDI prevalence than those without cirrhosis. Liver cirrhosis may be an independent risk factor for CDI. Further prospective studies are needed to clarify this possible risk association that may lead to the implementation of screening methods in this high-risk population.
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Affiliation(s)
- Syeda Sahra
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Mohammad Abureesh
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Shivantha Amarnath
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Motasem Alkhayyat
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Rawan Badran
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Abdullah Jahangir
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
| | - Vivek Gumaste
- Department of Gastroenterology, Staten Island University Hospital, Staten Island, NY 10305, United States
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Campbell KA, Trivedi HD, Chopra S. Infections in Cirrhosis: A Guide for the Clinician. Am J Med 2021; 134:727-734. [PMID: 33607090 DOI: 10.1016/j.amjmed.2021.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/31/2020] [Accepted: 01/25/2021] [Indexed: 12/13/2022]
Abstract
Cirrhosis contributes significantly to morbidity and mortality worldwide. Infections in patients with cirrhosis are common and significantly impact health-related quality of life. As our understanding of immune dysfunction associated with cirrhosis grows and as rates of drug-resistant organisms increase, the management of infections in cirrhosis has become increasingly nuanced. In this review, we discuss the current understanding of cirrhosis-associated immune deficiency, review the most common infections in patients with cirrhosis, and highlight techniques for the general clinician in the prevention and treatment of infections in this high-risk population.
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Affiliation(s)
- Kirsti A Campbell
- Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Hirsh D Trivedi
- Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Sanjiv Chopra
- Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass
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Acharya R, Poudel D, Patel A, Schultz E, Bourgeois M, Paswan R, Stockholm S, Batten M, Kafle S, Atkinson A, Sarwar H. Low serum albumin and the risk of hospitalization in COVID-19 infection: A retrospective case-control study. PLoS One 2021; 16:e0250906. [PMID: 33930096 PMCID: PMC8087007 DOI: 10.1371/journal.pone.0250906] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/16/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The data on the COVID-19 patients who were discharged to self-quarantine is lacking. AIM The aim of the study was to investigate the percentage of COVID-19 positive patients that were hospitalized within a three-week period after discharge from ED to self-quarantine. METHODS The patients who had confirmed SARS-CoV-2 on RT-PCR of the nasopharyngeal swab and were discharged from ED of a tertiary care hospital in the USA to self-quarantine from March 01- July 31, 2020, were included. Patients were divided into two groups based on serum albumin levels and were followed up for three weeks to see if low level of albumin increased the risk of hospitalization. Univariate and multivariate logistic regression analyses were performed to study the effect of albumin level and outcomes. RESULTS A total of 112 patients were included in the study out of which 65 had low serum albumin (<3.5 g/dL) and 47 had normal serum albumin (≥3.5 g/dL). More than 10% of patients discharged to self-quarantine needed hospitalization within three weeks. The Low albumin group had more co-morbidities at baseline. The low serum albumin group had 10 (15.38%) vs 2 (4.26%), p = 0.06 hospitalizations as compared to the normal serum albumin group. The multivariate logistic regression analysis did not reveal lower odds of hospitalization in the group with normal albumin, (OR 0.26, 95% CI 0.03-1.92, p = 0.19) after controlling for age, sex, and various co-morbidities. CONCLUSION The low serum albumin was not associated with the risk of hospitalization in COVID-19 patients who were initially discharged to self-quarantine.
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Affiliation(s)
- Roshan Acharya
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Dilli Poudel
- Department of Rheumatology, Indiana Regional Medical Center, Indiana, PA, United States of America
| | - Aakash Patel
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Evan Schultz
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Michael Bourgeois
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Rishi Paswan
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Scott Stockholm
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Macylen Batten
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Smita Kafle
- RN-BSN Program, Fayetteville State University, Fayetteville, NC, United States of America
| | - Amanda Atkinson
- Department of Emergency Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
- Department of Critical Care Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Hafiz Sarwar
- Department of Critical Care Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
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Wiedermann CJ. Hypoalbuminemia as Surrogate and Culprit of Infections. Int J Mol Sci 2021; 22:4496. [PMID: 33925831 PMCID: PMC8123513 DOI: 10.3390/ijms22094496] [Citation(s) in RCA: 117] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 02/07/2023] Open
Abstract
Hypoalbuminemia is associated with the acquisition and severity of infectious diseases, and intact innate and adaptive immune responses depend on albumin. Albumin oxidation and breakdown affect interactions with bioactive lipid mediators that play important roles in antimicrobial defense and repair. There is bio-mechanistic plausibility for a causal link between hypoalbuminemia and increased risks of primary and secondary infections. Serum albumin levels have prognostic value for complications in viral, bacterial and fungal infections, and for infectious complications of non-infective chronic conditions. Hypoalbuminemia predicts the development of healthcare-associated infections, particularly with Clostridium difficile. In coronavirus disease 2019, hypoalbuminemia correlates with viral load and degree of acute lung injury and organ dysfunction. Non-oncotic properties of albumin affect the pharmacokinetics and pharmacodynamics of antimicrobials. Low serum albumin is associated with inadequate antimicrobial treatment. Infusion of human albumin solution (HAS) supplements endogenous albumin in patients with cirrhosis of the liver and effectively supported antimicrobial therapy in randomized controlled trials (RCTs). Evidence of the beneficial effects of HAS on infections in hypoalbuminemic patients without cirrhosis is largely observational. Prospective RCTs are underway and, if hypotheses are confirmed, could lead to changes in clinical practice for the management of hypoalbuminemic patients with infections or at risk of infectious complications.
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Affiliation(s)
- Christian J. Wiedermann
- Institute of General Practice, Claudiana–College of Health Professions, 39100 Bolzano, Italy;
- Department of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, 6060 Hall in Tyrol, Austria
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Proton pump inhibitor use and mortality in patients with cirrhosis: a meta-analysis of cohort studies. Biosci Rep 2021; 40:224145. [PMID: 32406491 PMCID: PMC7276520 DOI: 10.1042/bsr20193890] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Proton pump inhibitor (PPI) is commonly used in patients with cirrhosis. However, some studies demonstrated that PPI use was associated with adverse outcome in patients with cirrhosis. We aimed to perform a meta-analysis of cohort studies to evaluate the association between PPI use and mortality in cirrhotic patients. Methods: Relevant studies were obtained via search of PubMed and Embase databases. A randomized-effect model was used to pool the results. Subgroup analyses were performed to evaluate the source of heterogeneity. Results: Overall, 21 cohort studies with 20,899 patients and 7457 death events were included. The pooled results with a randomized-effect model showed that PPI use was associated with significantly increased risk of mortality in patients with cirrhosis (adjusted relative risk [RR] = RR: 1.39, P<0.001) with considerable heterogeneity (I2=73%). Subgroup analyses showed that characteristics such as patient ethnicity, sample size, definition of PPI use, and complications of patients did not affect the association. However, the association between PPI use and mortality was independent of study characteristics including patient ethnicity, sample size, complications, definition of PPI use, and follow-up duration. However, the association between PPI use and mortality in cirrhotic patients was significant in retrospective studies (RR: 1.40, P<0.001), but not in prospective studies (RR: 1.34, P=0.33). Conclusions: PPI use may be associated with moderately increased mortality in cirrhotic patients. Although prospective cohort studies are needed to validate our findings, PPI should only prescribed to cirrhotic patients with indications for the treatment.
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Lee DU, Fan GH, Ahern RR, Karagozian R. The effect of malnutrition on the infectious outcomes of hospitalized patients with cirrhosis: analysis of the 2011-2017 hospital data. Eur J Gastroenterol Hepatol 2021; 32:269-278. [PMID: 33252419 DOI: 10.1097/meg.0000000000001991] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with cirrhosis, there is a clinical concern that the development of protein-calorie malnutrition will affect the immune system and predispose these patients to increased infectious outcomes. AIMS In this study, we evaluate the effects of malnutrition on the infectious outcomes of patients admitted with cirrhosis. MATERIALS AND METHODS This study used the 2011-2017 National Inpatient Sample to identify patients with cirrhosis. These patients were stratified using malnutrition (protein-calorie malnutrition, cachexia, and sarcopenia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. The endpoints included mortality and infectious outcomes. RESULTS After matching, there were 96 842 malnutrition-present cohort and equal number of controls. In univariate analysis, the malnutrition cohort had higher hospital mortality [10.40 vs. 5.04% P < 0.01, odds ratio (OR) 2.18, 95% confidence interval (CI) 2.11-2.26]. In multivariate models, malnutrition was associated with increased mortality [P < 0.01, adjusted odds ratio (aOR) 1.32, 95% CI 1.27-1.37] and infectious outcomes, including sepsis (P < 0.01, aOR 1.94, 95% CI 1.89-2.00), pneumonia (P < 0.01, aOR 1.68, 95% CI 1.63-1.73), UTI (P < 0.01, aOR 1.39, 95% CI 1.35-1.43), cellulitis (P < 0.01, aOR 1.09, 95% CI 1.05-1.13), cholangitis (P < 0.01, aOR 1.39, 95% CI 1.26-1.55), and clostridium difficile (P < 0.01, aOR 2.11, 95% CI 1.92-2.31). CONCLUSION The results of this study indicate that malnutrition is an independent risk factor of hospital mortality and local/systemic infections in patients admitted with cirrhosis.
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Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology, Liver Center, Tufts Medical Center, 800 Washington Street, Boston, Massachusetts, USA
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Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is common in patients with cirrhosis and is associated with poor outcomes. CDI risk factors in this population have been well characterized; however, risk factors of recurrent CDI (R-CDI) after treatment have not been explored. We sought to estimate the incidence of R-CDI and its associated risk factors in patients with cirrhosis. METHODS We performed a cohort study of patients with cirrhosis hospitalized with CDI between 2012 and 2016. We collected patient characteristics, including detailed information on the CDI, features of the underlying liver disease, and outcomes including R-CDI, hospital readmission, and mortality. R-CDI was defined as CDI occurring 2-8 weeks after the initial episode. Cox proportional hazards model was used to identify variables independently associated with the outcomes. RESULTS A total of 257 hospitalized patients with cirrhosis and CDI were included. CDI was community associated in 22.6%. The incidence of R-CDI was 11.9%. R-CDI was not significantly associated with medications at hospital admission or discharge. Independent risk factors of R-CDI included increased Charlson Comorbidity Index (hazard ratio [HR] 1.30; 95% confidence interval [CI]: 1.09-1.55) and use of lactulose (HR 2.58; 95% CI: 1.09-6.09). The 30-day readmission rate was 37%, and readmission was associated with increased Charlson Comorbidity Index (HR 1.12; 95% CI: 1.03-1.23) and Model for End-Stage Liver Disease score (HR 1.04; 95% CI: 1.01-1.07). The 90-day mortality was 22.8%. DISCUSSION In patients with cirrhosis, R-CDI is associated with comorbidity burden and lactulose use. Attention to these factors might aid clinicians in efforts to prevent R-CDI and improve outcomes in this population.
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Abdalla AO, Pisipati S, Elnaggar M, Rishi M, Doshi R, Gullapalli N. Outcomes of Clostridioides difficile Infection in Patients With Liver Cirrhosis: A Nationwide Study. Gastroenterology Res 2020; 13:53-57. [PMID: 32362963 PMCID: PMC7188361 DOI: 10.14740/gr1240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 02/08/2020] [Indexed: 12/18/2022] Open
Abstract
Background Clostridioides difficile infection (CDI) is a major health problem that has been on the rise for the last couple of decades. It has significant mortality and morbidity in hospitalized patients. We looked at the outcomes of CDI in patients with liver cirrhosis compared to those without liver cirrhosis. Methods We conducted a retrospective study from a large inpatient database. The National Inpatient Sample (NIS) was queried for CDI admissions between January 2012 and September 2015. Patients admitted with CDI were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The outcomes included overall mortality, length of hospitalization, and healthcare expenditure related to hospitalization. Results Out of all patients, 53,765 (3.97%) had concurrent CDI and liver cirrhosis. Diabetes mellitus, alcohol abuse, and acquired immunodeficiency were observed more in patients with liver cirrhosis. Overall mortality (adjusted odds ratio (aOR) 1.65, 95% confidence interval (CI) 1.53 - 1.77, P < 0.001), cost of hospitalization and length of hospital stay (11.0 vs. 10.4 days, P < 0.001) were significantly higher in patients with cirrhosis. Conclusions Patients with CDI and liver cirrhosis have significantly higher mortality, prolonged hospitalization and healthcare expenditure. Further studies are recommended to look at reversible risk factors for CDI in patients with liver cirrhosis to guide quality measures that would ultimately improve outcomes.
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Affiliation(s)
- Abubaker O Abdalla
- Department of Hospital Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Sailaja Pisipati
- Department of Internal Medicine, University of Nevada, School of Medicine, 1155 Mill St W11, Reno, NV 89502, USA
| | - Mohamed Elnaggar
- Department of Internal Medicine, University of Nevada, School of Medicine, 1155 Mill St W11, Reno, NV 89502, USA
| | - Mohit Rishi
- Department of Internal Medicine, University of Nevada, School of Medicine, 1155 Mill St W11, Reno, NV 89502, USA
| | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada, School of Medicine, 1155 Mill St W11, Reno, NV 89502, USA
| | - Nageshwara Gullapalli
- Department of Internal Medicine, University of Nevada, School of Medicine, 1155 Mill St W11, Reno, NV 89502, USA
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Early Readmission Predicts Increased Mortality in Cirrhosis Patients After Clostridium difficile Infection. J Clin Gastroenterol 2019; 53:e322-e327. [PMID: 30045168 DOI: 10.1097/mcg.0000000000001090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
GOALS We sought to determine the impact of Clostridium difficile infections (CDI) in cirrhosis by evaluating trends and outcomes of early readmission and mortality. BACKGROUND The incidence of CDI in cirrhotics is increasing. STUDY We analyzed the Nationwide Readmissions Database (2011 to 2014) for hospitalized patients with CDI and differentiated them by presence of cirrhosis. Baseline characteristics, surgical rates, and outcomes were collected. The primary outcomes of interest included readmission and mortality rates. RESULTS Of 366,283 patients hospitalized with CDI, 12,274 (3.4%) had cirrhosis, of which 7741 (63.1%) were decompensated. Among patients with CDI, 30-day readmission rates (33% vs. 24%), index admission mortality (5% vs. 2.5%), and calendar-year mortality (9% vs. 4%) were higher in patients with cirrhosis compared with those without cirrhosis. Recurrent CDI (rCDI) (46%) and cirrhosis-related complications (34.6%) were the most common reasons for readmission. Patients with decompensated cirrhosis were more likely to be readmitted within 30-days than those with compensated cirrhosis [odds ratio (OR), 1.19; 95% confidence interval (CI), 1.03-1.36]. Multivariable analyses revealed that among patients with cirrhosis, index colectomy (OR, 6.50; 95% CI, 1.61-26.24) and decompensation (OR, 3.61; 95% CI, 2.49-5.23) predicted index admission mortality. In addition, 30-day readmission (OR, 3.71; 95% CI, 2.95-4.67) and decompensated cirrhosis (OR, 1.49; 95% CI, 1.17-1.89) independently predicted calendar-year mortality. CONCLUSIONS One-third of CDI patients with cirrhosis were readmitted within 30-days, most commonly because of rCDI. The mortality associated with CDI in patients with cirrhosis is high, with decompensation and 30-day readmission heralding a poor prognosis. Reducing rCDI-related readmissions may potentially improve these outcomes.
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Risk factors for Clostridium difficile infection in cirrhotic patients. Hepatobiliary Pancreat Dis Int 2019; 18:237-241. [PMID: 31029554 DOI: 10.1016/j.hbpd.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 04/11/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cirrhotic patients are susceptible to Clostridium difficile infection (CDI), however, the high risk factors are not clear. The present study aimed to identify the risk factors in cirrhotic patients with CDI. METHODS A total of 526 cirrhotic patients admitted to our hospital between May 2015 and October 2015 were included in this study. Stool samples were collected upon admission for the detection of CDI and toxin. CDI was monitored during the hospital stay. In total, 34 cases showed CDI. Then we analyzed the effects of age, sex, C. difficile colonization (CDC), multiple hospitalization, extended hospital stay, elevation of total bilirubin (TBIL), creatinine (Cr), Child-Pugh grade C, hepatic encephalopathy, hepatorenal syndrome, upper gastrointestinal hemorrhage, and exposure of antibiotics and proton pump inhibitor (PPI) on the CDI in cirrhotic patients. RESULTS Patients in the CDI group had more frequent CDC, multiple hospitalization, and extended hospital stay compared to those in the non-C. difficile infection (NCDI) group. Patients in the CDI group had higher TBIL and Cr, and higher frequency of Child-Pugh grade C, hepatic encephalopathy, upper gastrointestinal hemorrhage compared with those in the NCDI group. Multiple logistic regression analysis indicated that age >60 years (OR=1.689; 95% CI: 1.135-3.128), multiple hospitalization (OR=3.346; 95% CI: 1.392-8.043), length of hospital stay >20 days (OR=1.564; 95% CI: 1.113-2.563), hypoproteinemia (OR=4.962; 95% CI: 2.053-11.996), CDC (OR=18.410; 95% CI: 6.898-49.136), hepatic encephalopathy (OR=1.357; 95% CI: 1.154-2.368), and exposure of antibiotics (OR=1.865; 95% CI: 1.213-2.863) and PPI (OR=3.125; 95% CI: 1.818-7.548) were risk factors of CDI. CONCLUSIONS Age >60 years, multiple hospitalization, length of hospital stay >20 days, hypoproteinemia, CDC, hepatic encephalopathy, and exposure of antibiotics and PPI were risk factors for CDI in cirrhotic patients. These may contribute to the early diagnosis and monitoring of CDI in clinical practice.
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MELD is the only predictor of short-term mortality in cirrhotic patients with C. difficile infection. Dig Liver Dis 2019; 51:275-280. [PMID: 30172651 DOI: 10.1016/j.dld.2018.07.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/09/2018] [Accepted: 07/25/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is the most common nosocomial infection in the US and cirrhotic patients with CDI have increased risk for poor outcome. AIM The aim of this study is to evaluate the impact of CDI on short-term mortality in patients with cirrhosis and identify predictors of mortality in these patients. METHODS We retrospectively identified patients at Montefiore Medical Center from 2010 to 2014 with cirrhosis, diarrhea and a C. difficile toxin assay. Demographics, co-morbidities, medications, laboratory data and outcomes were recorded. RESULTS Of 701 patients with cirrhosis who had a CDI assay, 183 were CDI+ and 518 CDI-. Patients with CDI were older, had more frequent CKD on hemodialysis and heart failure, were less frequently on rifaximin and lactulose and had increased glucocorticoid exposure. 30-day mortality was higher in patients with CDI (23.0% vs 16.6%, p < 0.05) compared to those without. Univariate predictors of 30-day mortality included WBC, corticosteroid use, AST, ALT, MELD, albumin, HBV and HCV infection; however, via multivariate analysis, only MELD (HR: 1.04 ± 0.02, p < 0.05) remained significant. CONCLUSION Patients with cirrhosis and CDI are at greater risk of 30-day mortality than those without CDI and the only multivariate predictor of mortality is MELD. These patients should have their disease severity triaged based upon MELD score.
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