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Winget MD, Gatwood K, Jayani R, Biltibo E, Jallouk A, Jerkins J, Dholaria B, Kim TK, Savani B, Kassim A, McNeer E, Choi L, Orton L. Evaluating Antibiotic De-escalation for Autologous Stem Cell Transplant Patients With Febrile Neutropenia in a Real-World Clinical Setting. Transplant Cell Ther 2024:S2666-6367(24)00550-5. [PMID: 39074685 DOI: 10.1016/j.jtct.2024.07.020] [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: 06/07/2024] [Revised: 07/25/2024] [Accepted: 07/25/2024] [Indexed: 07/31/2024]
Abstract
Febrile neutropenia (FN) is a complication in approximately 90% of autologous stem cell transplant (SCT) patients. Guidelines support early broad-spectrum antibiotics (BSA) to prevent morbidity and mortality. However, in patients who are clinically stable and deemed to have a fever of unknown origin, the optimal duration of BSA is unknown. Accumulating evidence suggests that de-escalation of BSA in select patients may decrease duration of BSA exposure without compromising clinical outcomes such as infection, recurrent fever, and readmission. With this, a de-escalation protocol was implemented at Vanderbilt University Medical Center (VUMC) to identify autologous SCT patients who may benefit from early de-escalation of BSA. The objectives of this study were to analyze the impact of early empiric antibiotic de-escalation on the duration of BSA as well as its impact on the incidence of recurrent fever and documented infection in autologous SCT patients. This was a single-center, retrospective study evaluating patients older than 18 years of age who underwent autologous SCT and experienced an episode of FN from January 2018 to December 2022 at VUMC (N = 195). The protocol was initiated on January 1, 2020, to de-escalate BSA back to prophylaxis in stable neutropenic patients determined to have a fever of unknown origin. The primary outcome was the number of BSA days within 30 days. Secondary clinical outcomes included recurrent fever, documented infection, readmission, 30-day mortality, and 90-day non-relapsed mortality (NRM). Outcomes were compared across pre- and postprotocol groups with a Wilcoxon rank sum test, Pearson chi-square test, or regression analysis as appropriate. The median BSA duration was 4.7 and 2.7 days in the pre- and postprotocol groups, respectively (P < .001). Recurrent fever (14.2% versus 16.0%, P = .726), documented infection (1.7% versus 6.7%, P = .068), and readmission (13.3% versus 22.7%, P = .091) within 30 days were not significantly different between the two groups. Neither 30-day mortality (0.8% versus 1.3%, P = .736) nor 90-day NRM (0.8% versus 1.3%, P = .736) differed. The implementation of an early de-escalation protocol for autologous SCT patients who develop FN was associated with a reduction in duration of BSA compared to the preprotocol group without a significant difference in readmission, recurrent fevers, and documented infections. This study adds to existing evidence that early de-escalation of BSA in FN patients with a fever of unknown origin who are afebrile and clinically stable is safe and reduces unnecessary antibiotic use.
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Affiliation(s)
- Marshall D Winget
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Katie Gatwood
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reena Jayani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eden Biltibo
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Jallouk
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Jerkins
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bhagirathbhai Dholaria
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tae Kon Kim
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bipin Savani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adetola Kassim
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth McNeer
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lindsay Orton
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
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Deshpande A, O'Brien J, Hamilton B, Pappas M. Clinical Characteristics and Risk Factors for Clostridioides difficile Infection in the Hematopoietic Cell Transplantation Population. RESEARCH SQUARE 2024:rs.3.rs-4531064. [PMID: 39041031 PMCID: PMC11261972 DOI: 10.21203/rs.3.rs-4531064/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Background Hematopoietic cell transplantation (HCT) recipients are at increased risk of developing primary and recurrent Clostridioides difficile infection (CDI). The objective of our study was to characterize the risk factors for primary and recurrent CDI in a large cohort of patients hospitalized for HCT. Methods We conducted a retrospective cohort study of adults who underwent HCT from 2010-2023 to analyze the epidemiology, timing, and risk factors for CDI. We compared patients who developed CDI with those who did not, controlling for patient demographics, comorbidities, transplant factors, medications, and laboratory values. Results Of the 2,725 adults who underwent HCT, 252 (9.3%) developed primary CDI within one-year of transplantation. The incidence was higher among allogenic HCT recipients (17.8%) compared to autologous recipients (4.1%). Independent risk factors for primary CDI included receipt of penicillin antibiotics, prior chemotherapy, and umbilical cord stem cells. Receipt of macrolide antibiotics was an independent risk factor for recurrent CDI, while receipt of autologous HCT was associated with a reduced risk of both primary and recurrent CDI. Conclusions CDI presents an early complication after HCT, particularly in allogenic recipients who experience higher incidence rates and severe complications. Early recognition and management of these risk factors are essential to prevent these adverse outcomes.
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Ragozzino S, Mueller NJ, Neofytos D, Passweg J, Müller A, Medinger M, Van Delden C, Masouridi-Levrat S, Chalandon Y, Tschudin-Sutter S, Khanna N. Epidemiology, outcomes and risk factors for recurrence of Clostridioides difficile infections following allogeneic hematopoietic cell transplantation: a longitudinal retrospective multicenter study. Bone Marrow Transplant 2024; 59:278-281. [PMID: 38036657 PMCID: PMC10849940 DOI: 10.1038/s41409-023-02157-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/07/2023] [Accepted: 11/16/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Silvio Ragozzino
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Dionysios Neofytos
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Jakob Passweg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Antonia Müller
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
- Department of Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria
| | - Michael Medinger
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Christian Van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Stavroula Masouridi-Levrat
- Division of Hematology, University Hospitals Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Yves Chalandon
- Division of Hematology, University Hospitals Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
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4
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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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Kwon JH, Nickel KB, Reske KA, Stwalley D, Lyons PG, Michelson A, McMullen K, Sahrmann JM, Gandra S, Olsen MA, Dubberke ER, Burnham JP. Risk factors for hospital-onset Clostridioides difficile infections before and during the severe acute respiratory syndrome coronavirus 2 pandemic. Am J Infect Control 2023; 51:1285-1287. [PMID: 37263419 PMCID: PMC10228158 DOI: 10.1016/j.ajic.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/03/2023]
Abstract
In this retrospective cohort from 3 Missouri hospitals from January 2017 to August 2020, hospital-onset Clostridioides difficile infections were more common during the severe acute respiratory syndrome coronavirus 2 pandemic at the tertiary care hospital. Risk factors associated with hospital-onset C difficile infection included the year of hospitalization, age, high-risk antibiotic use, acid-reducing medications, chronic comorbidities, and severe acute respiratory syndrome coronavirus 2 infection.
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Affiliation(s)
- Jennie H Kwon
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Katelin B Nickel
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Kimberly A Reske
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Dustin Stwalley
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Andrew Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | | | - John M Sahrmann
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Sumanth Gandra
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Margaret A Olsen
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Erik R Dubberke
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO.
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Lo Porto D, Mularoni A, Castagnola E, Saffioti C. Clostridioides difficile infection in the allogeneic hematopoietic cell transplant recipient. Transpl Infect Dis 2023; 25 Suppl 1:e14159. [PMID: 37787395 DOI: 10.1111/tid.14159] [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: 08/10/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
Clostridioides difficile (CD) is one of the most important causes of diarrhea in hospitalized patients, in particular those who undergo an allogeneic hematopoietic cell transplant (allo-HCT) and who are more at risk of developing a CD infection (CDI) due to frequent hospitalizations, iatrogenic immunosuppression, and prolonged antibiotic cycles. CDI may represent a severe condition in allo-HCT patients, increasing the length of hospitalization, influencing the intestinal microbiome with a bidirectional association with graft-versus-host disease, and leading to unfavorable outcomes, including death. The diagnosis of CDI requires the exclusion of other probable causes of diarrhea in HCT patients and is based on highly sensitive and highly specific tests to distinguish colonization from infection. In adult patients, fidaxomicin is recommended as first-line, with oral vancomycin as an alternative agent. Bezlotoxumab may be used to reduce the risk of recurrence. In pediatric patients, vancomycin and metronidazole are still suggested as first-line therapy, but fidaxomicin will probably become standard in pediatrics in the near future. Because of insufficient safety data, fecal microbiota transplantation is not routinely recommended in HCT in spite of promising results for the management of recurrences in other populations.
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Affiliation(s)
- Davide Lo Porto
- Unit of Infectious Diseases, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Alessandra Mularoni
- Unit of Infectious Diseases, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Elio Castagnola
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Carolina Saffioti
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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7
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Ramanathan M, Kim S, He N, Chen M, Hematti P, Abid MB, Rotz SJ, Williams KM, Lazarus HM, Wirk B, Yin DE, Kanakry CG, Perales MA, Chemaly RF, Dandoy CE, Riches M, Ustun C. The incidence and impact of clostridioides difficile infection on transplant outcomes in acute leukemia and MDS after allogeneic hematopoietic cell transplant-a CIBMTR study. Bone Marrow Transplant 2023; 58:360-366. [PMID: 36543999 PMCID: PMC10079570 DOI: 10.1038/s41409-022-01896-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
Clostridioides difficile infection (CDI) is common after allogeneic hematopoietic cell transplantation (alloHCT). The determination of incidence, risk factors, and impact of CDI on alloHCT outcomes is an unmet need. The study examines all patients aged 2 years and older who received first alloHCT for acute myeloid leukemia (AML), acute lymphocytic leukemia (ALL), or myelodysplastic syndrome (MDS) between 2013 and 2018 at US centers and reported to the Center for International Blood and Marrow Transplant Research (CIBMTR) data registry. In total, 826 patients with CDI and 6723 controls from 127 centers were analyzed. The cumulative incidence of CDI by day 100 was 18.7% (99% CI: 15-22.7%) and 10.2% (99% CI: 9.2-11.1%) in pediatric and adult patients, respectively, with a median time to diagnosis at day +13. CDI was associated with inferior overall survival (OS) (p = 0.0018) and a 2.58-fold [99% CI: 1.43-4.66; p < 0.001] increase in infection-related mortality (IRM). There was a significant overlap in the onset of acute graft versus host disease (aGVHD) and CDI. IRM increased to >4 fold when CDI + aGVHD was considered. Despite advances in the management of CDI, increased IRM and decreased OS still results from CDI.
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Affiliation(s)
- Muthalagu Ramanathan
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA.
| | - Soyoung Kim
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Naya He
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Min Chen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Muhammad Bilal Abid
- Divisions of Hematology/Oncology & Infectious Diseases, BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | | | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, PA, USA
| | - Dwight E Yin
- Divisions of Infectious Diseases and Clinical Pharmacology, Department of Pediatrics, Children's Mercy Kansas City and University of Missouri at Kansas City, Kansas City, MO, USA
| | - Christopher G Kanakry
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | | | - Christopher E Dandoy
- Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Marcie Riches
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Celalettin Ustun
- Division of Hematology/Oncology/Cell Therapy, Rush University, Chicago, IL, USA
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8
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de Almeida C, Wong M, Kleijn HJ, Wrishko RE. Predicted Bezlotoxumab Exposure in Patients Who Have Received a Hematopoietic Stem Cell Transplant. Clin Ther 2023; 45:356-362. [PMID: 36906440 DOI: 10.1016/j.clinthera.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/06/2023] [Accepted: 02/14/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE Bezlotoxumab is approved for prevention of recurrent Clostridioides (Clostridium) difficile infection (CDI) in adults receiving antibacterial treatment for CDI who are at high risk for recurrent CDI. Previous studies have shown that although serum albumin levels are an important predictor for bezlotoxumab exposure, this has no clinically meaningful impact on efficacy. This pharmacokinetic modeling study assessed whether hematopoietic stem cell transplant (HSCT) recipients, at increased risk of CDI and exhibiting decreased albumin levels within the first month posttransplant, are at risk of clinically relevant reductions in bezlotoxumab exposure. METHODS Observed bezlotoxumab concentration-time data pooled from participants in Phase III trials MODIFY I and II (ClinicalTrials.gov identifiers NCT01241552/NCT01513239) and three Phase I studies (PN004, PN005, and PN006) were used to predict bezlotoxumab exposures in two adult post-HSCT populations: A Phase Ib study of posaconazole including allogeneic HSCT recipients (ClinicalTrials.gov identifier NCT01777763; posaconazole-HSCT population); and a Phase III study of fidaxomicin for CDI prophylaxis (ClinicalTrials.gov identifier NCT01691248; fidaxomicin-HSCT population). The bezlotoxumab PK model used the minimum albumin level for each individual in post-HSCT populations to mimic a "worst-case scenario." FINDINGS Predicted worst-case bezlotoxumab exposures for the posaconazole-HSCT population (N = 87) were decreased by 10.8% versus bezlotoxumab exposures observed in the pooled Phase III/Phase I data set (N = 1587). No further decrease was predicted for the fidaxomicin-HSCT population (N = 350). IMPLICATIONS Based on published population pharmacokinetic data, the predicted decrease in bezlotoxumab exposure in the post-HSCT populations is not expected to have a clinically meaningful effect on bezlotoxumab efficacy at the recommended 10 mg/kg dose. Dose modification is therefore not required in the hypoalbuminemia setting expected post-HSCT. (Clin Ther. 2023;45:XXX-XXX) © 2023 Elsevier HS Journals, Inc.
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Affiliation(s)
| | | | - Huub Jan Kleijn
- Certara Strategic Consulting Services, Princeton, New Jersey, USA
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9
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Alonso CD, Maron G, Kamboj M, Carpenter PA, Gurunathan A, Mullane KM, Dubberke ER. American Society for Transplantation and Cellular Therapy Series: #5-Management of Clostridioides difficile Infection in Hematopoietic Cell Transplant Recipients. Transplant Cell Ther 2022; 28:225-232. [PMID: 35202891 DOI: 10.1016/j.jtct.2022.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 12/17/2022]
Abstract
The Practice Guidelines Committee of the American Society for Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to update its 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A completely new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease and HCT content experts developed and then answered FAQs and finalized topics with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. This fifth guideline in the series focuses on Clostridioides difficile infection with FAQs that address the prevalence, incidence, clinical features, colonization versus infection, clinical complications, diagnostic considerations, pharmacological therapies for episodic or recurrent infection, and the roles of prophylactic antibiotics, probiotics, and fecal microbiota transplantation.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Mini Kamboj
- Division of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Kathleen M Mullane
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, Illinois
| | - Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri
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10
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Luo Y, Zhang S, Shang H, Cui W, Wang Q, Zhu B. Prevalence of Clostridium difficile Infection in the Hematopoietic Transplantation Setting: Update of Systematic Review and Meta-Analysis. Front Cell Infect Microbiol 2022; 12:801475. [PMID: 35265530 PMCID: PMC8900492 DOI: 10.3389/fcimb.2022.801475] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022] Open
Abstract
Hematopoietic stem cell transplant (HSCT) recipients are vulnerable to Clostridium difficile infection (CDI) due to risk factors such as immunosuppression, antimicrobial use, and frequent hospitalization. We systematically searched PubMed and Embase to screen relevant studies from April 2014 to November 2021. A meta-analysis was performed to identify the association between CDI and hematopoietic transplantation based on the standard mean difference and 95% confidence intervals (CIs). Among the 431 retrieved citations, we obtained 43 eligible articles, which included 15,911 HSCT patients at risk. The overall estimated prevalence of CDI was 13.2%. The prevalence of CDI among the 10,685 allogeneic transplantation patients (15.3%) was significantly higher than that among the 3,840 autologous HSCT recipients (9.2%). Different incidence rates of CDI diagnosis over the last 7 years were found worldwide, of which North America (14.1%) was significantly higher than Europe (10.7%) but not significantly different from the prevalence among Asia (11.6%). Notably, we found that the estimated prevalence of CDI diagnosed by polymerase chain reaction (PCR) (17.7%) was significantly higher than that diagnosed by enzyme immunoassay (11.5%), indicating a significant discrepancy in the incidence rate of CDI owing to differences in the sensibility and specificity of the detection methods. Recurrence of CDI was found in approximately 15% of the initial patients with CDI. Furthermore, 20.3% of CDI cases were severe. CDI was found to be a common complication among HSCT recipients, displaying an evident increase in the morbidity of infection.
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Affiliation(s)
- Ying Luo
- Department of Clinical Laboratory, Zibo Central Hospital, Zibo, China
| | - Sumei Zhang
- Department of Respiratory Medicine, Zibo Central Hospital, Zibo, China
| | - Hua Shang
- Department of Gastroenterology, Zibo Central Hospital, Zibo, China
| | - Weitong Cui
- Key Laboratory of Biomedical Engineering & Technology of Shandong High School, Qilu Medical University, Zibo, China
| | - Qinglu Wang
- College of Sport and Health, Shandong Sport University, Jinan, China
- *Correspondence: Qinglu Wang,
| | - Bin Zhu
- Department of Clinical Laboratory, Zibo Central Hospital, Zibo, China
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Kubiak J, Davidson E, Soave R, Kodiyanplakkal RP, Robertson A, Besien KV, Shore TB, Lee JR, Westblade LF, Satlin MJ. Colonization with Gastrointestinal Pathogens Prior to Hematopoietic Cell Transplantation and Associated Clinical Implications. Transplant Cell Ther 2021; 27:499.e1-499.e6. [PMID: 33811020 DOI: 10.1016/j.jtct.2021.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
Infectious diarrhea following hematopoietic cell transplantation (HCT) significantly contributes to morbidity and mortality. Most HCT recipients experience diarrhea in the post-transplantation period, and infectious pathogens are frequently detected during diarrheal episodes. However, little is known about how frequently these patients are colonized with gastrointestinal (GI) pathogens before their transplantation and whether colonization predicts future diarrheal illness. We sought to determine how frequently HCT recipients are colonized with GI pathogens before HCT and the degree to which pre-HCT colonization predicts post-transplantation infectious diarrheal illness. We conducted a prospective cohort study of allogeneic and autologous HCT recipients at a single center between December 2016 and January 2019. Stool samples were collected during the week before HCT, and formed samples were evaluated for the presence of 22 diarrheal pathogens using the BioFire FilmArray GI panel. We determined the frequency with which participants were colonized with each pathogen and identified factors associated with colonization. We then determined how frequently pretransplantation colonization led to post-transplantation diarrheal infections due to the colonizing pathogen and whether colonization was associated with increased number of days of post-transplantation diarrhea during the transplant hospitalization. We enrolled 112 asymptomatic patients (allogeneic, 61%; autologous, 39%) who had a formed stool specimen before HCT, of whom 41 (37%) had a GI pathogen detected. The most commonly detected organisms were Clostridioides difficile (n = 21; 19%), Yersinia enterocolitica (n = 9; 8%), enteropathogenic Escherichia coli (EPEC) (n = 6; 6%), and norovirus (n = 5; 4%). Female sex and previous C. difficile infection were associated with C. difficile colonization, and having non-Hodgkin lymphoma was associated with being colonized with a diarrheal pathogen other than C. difficile. Thirteen of 21 patients (62%) with pretransplantation C. difficile colonization developed a clinical C. difficile infection post-transplantation, and 8 of 10 patients (80%) colonized with EPEC or enteroaggregative E. coli developed post-transplantation infections due to their colonizing pathogen. Pretransplantation C. difficile colonization was also associated with an increased duration of post-transplantation diarrhea (P = .048). Conversely, none of the 9 patients with pretransplantation Yersinia enterocolitica colonization developed a post-transplantation Y. enterocolitica infection. Patients admitted for HCT are frequently colonized with a diverse range of GI pathogens. Colonization with C. difficile colonization and diarrheagenic E. coli is frequently associated with post-transplantation diarrheal infections caused by these organisms, but the clinical significance of colonization with other GI pathogens is not clear.
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Affiliation(s)
- Jeffrey Kubiak
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Emily Davidson
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Rosemary Soave
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Rosy Priya Kodiyanplakkal
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Amy Robertson
- New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Koen van Besien
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Tsiporah B Shore
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - John R Lee
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Lars F Westblade
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York; Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Michael J Satlin
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York; Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York.
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12
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Comorbidity and severity-of-illness risk adjustment for hospital-onset Clostridioides difficile infection using data from the electronic medical record. Infect Control Hosp Epidemiol 2020; 42:955-961. [PMID: 33327970 DOI: 10.1017/ice.2020.1344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether electronically available comorbidities and laboratory values on admission are risk factors for hospital-onset Clostridioides difficile infection (HO-CDI) across multiple institutions and whether they could be used to improve risk adjustment. PATIENTS All patients at least 18 years of age admitted to 3 hospitals in Maryland between January 1, 2016, and January 1, 2018. METHODS Comorbid conditions were assigned using the Elixhauser comorbidity index. Multivariable log-binomial regression was conducted for each hospital using significant covariates (P < .10) in a bivariate analysis. Standardized infection ratios (SIRs) were computed using current Centers for Disease Control and Prevention (CDC) risk adjustment methodology and with the addition of Elixhauser score and individual comorbidities. RESULTS At hospital 1, 314 of 48,057 patient admissions (0.65%) had a HO-CDI; 41 of 8,791 patient admissions (0.47%) at community hospital 2 had a HO-CDI; and 75 of 29,211 patient admissions (0.26%) at community hospital 3 had a HO-CDI. In multivariable regression, Elixhauser score was a significant risk factor for HO-CDI at all hospitals when controlling for age, antibiotic use, and antacid use. Abnormal leukocyte level at hospital admission was a significant risk factor at hospital 1 and hospital 2. When Elixhauser score was included in the risk adjustment model, it was statistically significant (P < .01). Compared with the current CDC SIR methodology, the SIR of hospital 1 decreased by 2%, whereas the SIRs of hospitals 2 and 3 increased by 2% and 6%, respectively, but the rankings did not change. CONCLUSIONS Electronically available patient comorbidities are important risk factors for HO-CDI and may improve risk-adjustment methodology.
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Clostridioides difficile Infection and Risk of Acute Graft-versus-Host Disease among Allogeneic Hematopoietic Stem Cell Transplantation Recipients. Transplant Cell Ther 2020; 27:176.e1-176.e8. [PMID: 33830032 DOI: 10.1016/j.jtct.2020.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 10/08/2020] [Accepted: 10/18/2020] [Indexed: 01/15/2023]
Abstract
Clostridioides difficile infection (CDI) is a major cause of infectious diarrhea among allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. The relationship between CDI and acute graft-versus-host disease (aGVHD) has been a topic of interest, as these 2 conditions may influence each other. We studied the temporal relationship of CDI to aGVHD in the first 100 days post-transplantation in a large cohort of allo-HSCT recipients. We performed a retrospective cohort study of adult patients undergoing their first allo-HSCT at our tertiary care medical center between January 1, 2010, and December 31, 2016. Patients were followed for CDI diagnosis, development of aGVHD, and vital status up to day +100 post-transplantation. Descriptive statistics and multivariate Cox models with CDI as a time-varying covariate and aGVHD and high-grade aGVHD as outcomes were used for data analyses. A total of 656 allo-HSCT recipients were included in the analysis. Of these, 419 (64%) developed aGVHD, and 111 (17%) were diagnosed with CDI within the first 100 days post-transplantation. CDI developed before the onset of aGVHD in 72 of the 84 allo-HSCT recipients (85%) with both CDI and aGVHD. Fidaxomicin was used in the treatment of 57 of the 111 CDI cases (50%), whereas vancomycin was used in 52 (47%). Most of the CDI cases (88%) were diagnosed in the peritransplantation period (between day -10 and day +10). The median time to the development of CDI and aGVHD was 3.5 days (range, -7 to 95 days) and 33 days (range, 9 to 98 days) post-transplantation, respectively. Using multivariate Cox model, the following predictors were significantly associated with the development of aGVHD: CDI (adjusted hazard ratio [aHR], 1.52; 95% confidence interval [CI], 1.17 to 1.97; P = .0018), transplantation from a matched related donor (MRD) compared with a matched unrelated donor (aHR, 0.68; 95% CI, 0.54 to 0.85; P = .0003), and myeloablative versus nonmyeloablative conditioning (aHR, 2.45; 95% CI, 1.80 to 3.34; P < .0001), adjusting for age, sex, race, underlying disease, cytomegalovirus CMV serostatus, transplant source, and receipt of antithymocyte globulin (ATG). There was no association between CDI and high-grade aGVHD after adjustment for age, underlying disease, transplant type, intensity of conditioning, and receipt of ATG (aHR, 1.59; 95% CI, 0.95 to 2.66; P = .0755). CDI after allo-HSCT is associated with increased risk of GVHD when no CDI prophylaxis was used. Further studies examining CDI preventive measures, including prophylaxis, as well as the preservation or reconstitution of the gastrointestinal microbiome in the setting of HSCT are warranted.
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14
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Weber S, Scheich S, Magh A, Wolf S, Enßle JC, Brunnberg U, Reinheimer C, Wichelhaus TA, Kempf VAJ, Kessel J, Vehreschild MJGT, Serve H, Bug G, Steffen B, Hogardt M. Impact of Clostridioides difficile infection on the outcome of patients receiving a hematopoietic stem cell transplantation. Int J Infect Dis 2020; 99:428-436. [PMID: 32798661 DOI: 10.1016/j.ijid.2020.08.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/02/2020] [Accepted: 08/07/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Clostridioides difficile infections (CDI) are common in autologous (auto-HSCT) or allogenic hematopoietic stem cell transplant (allo-HSCT) recipients. However, the impact of CDI on patient outcomes is controversial. We conducted this study to examine the impact of CDI on patient outcomes. METHODS We performed a retrospective single-center study, including 191 lymphoma patients receiving an auto-HSCT and 276 acute myeloid leukemia (AML) patients receiving an allo-HSCT. The primary endpoint was overall survival (OS). Secondary endpoints were causes of death and, for the allo-HSCT cohort, GvHD- and relapse-free survival (GRFS). RESULTS The prevalence of CDI was 17.6% in the AML allo-HSCT and 7.3% in the lymphoma auto-HSCT cohort. A higher prevalence of bloodstream infections, but no differences concerning OS or cause of death were found for patients with CDI in the auto-HSCT cohort. [AU] In the allo-HSCT cohort, OS and GRFS were similar between CDI and non-CDI patients. However, the leading cause of death was relapse among non-CDI patients, but it was infectious diseases in the CDI group with fewer deaths due to relapse. CONCLUSIONS CDI was not associated with worse survival in patients receiving a hematopoietic stem cell transplantation, and there were even fewer relapse-related deaths in the AML allo-HSCT cohort.
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Affiliation(s)
- Sarah Weber
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Scheich
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany.
| | - Aaron Magh
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sebastian Wolf
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Julius C Enßle
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Uta Brunnberg
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Claudia Reinheimer
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Thomas A Wichelhaus
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Volkhard A J Kempf
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Johanna Kessel
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Department of Medicine, Infectious Diseases Unit, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Maria J G T Vehreschild
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Department of Medicine, Infectious Diseases Unit, University Hospital Frankfurt, Frankfurt am Main, Germany; German Center of Infectious Diseases, Partner site Bonn-Cologne
| | - Hubert Serve
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Gesine Bug
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Björn Steffen
- Department of Hematology and Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Hogardt
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany; Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
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15
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Willis DN, Huang FS, Elward AM, Wu N, Magnusen B, Dubberke ER, Hayashi RJ. Clostridioides difficile Infections in Inpatient Pediatric Oncology Patients: A Cohort Study Evaluating Risk Factors and Associated Outcomes. J Pediatric Infect Dis Soc 2020; 10:302-308. [PMID: 32766672 PMCID: PMC8023311 DOI: 10.1093/jpids/piaa090] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/13/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is a significant source of morbidity in pediatric cancer patients. Few reports to date have evaluated risk factors and short-term outcomes for this population. METHODS We retrospectively evaluated pediatric oncology admissions at St Louis Children's Hospital from 2009 to 2018. All inpatient cases of diagnosed initial CDI were identified. We aimed to investigate the prevalence of CDI and associated risk factors, including coadmission with another patient with CDI, and to evaluate short-term outcomes including length of stay and delays in subsequent scheduled chemotherapy. RESULTS Review of 6567 admissions from 952 patients revealed 109 CDI cases (11.4% of patients). Patients with leukemia or lymphoma, compared to those with solid tumors, were more likely to have CDI (odds ratio [OR], 3 [95% CI, 1.4-6.6], and 3 [95% CI, 1.3-6.8], respectively). Autologous hematopoietic stem cell transplant (HSCT) was also a risk factor (OR, 3.5 [95% CI, 1.7-7.4]). Prior antibiotic exposure independently increased the risk for CDI (OR, 3.0 [95% CI, 1.8-4.8]). Concurrent admission with another patient with CDI also significantly increased the risk (OR, 84.7 [95% CI, 10.5-681.8]). In contrast to previous reports, exposure to acid-suppressing medications decreased the risk for CDI (OR, 0.5 [95% CI, .3-.7]). CDI was associated with increased length of stay (mean difference, 8 days [95% CI, 4.6-11.4]) and prolonged delays for subsequent chemotherapy (mean difference, 1.4 days [95% CI, .1-2.7]). CONCLUSIONS CDI in pediatric oncology patients significantly prolongs hospitalization and delays chemotherapy treatment plans. Interventions to control CDI will improve the care of pediatric oncology patients.
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Affiliation(s)
- Daniel N Willis
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St Louis, Missouri, USA,Correspondence: Daniel N. Willis, MD, Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, Box 8116, St Louis, MO 63110. E-mail:
| | - Frederick S Huang
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Alexis M Elward
- Division of Pediatric Infectious Disease, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ningying Wu
- Siteman Biostatistics Shared Resource, Washington University School of Medicine, St Louis, Missouri, USA
| | - Brianna Magnusen
- Institute for Informatics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Erik R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
| | - Robert J Hayashi
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St Louis, Missouri, USA
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16
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Abstract
The microbiome is an integrated part of the human body that can modulate a variety of disease processes and affect prognosis, treatment response, complications, and outcomes. The importance of allogeneic hematopoietic cell transplantation in cancer treatment has resulted in extensive investigations on the interaction between the microbiome and this treatment modality. These investigations are beginning to lead to clinical trials of microbiome-targeted interventions. Here we review some of these discoveries and describe strategies being investigated to manipulate the microbiome for favorable outcomes, such as the proper selection and timing of antibiotics, type of diet and route of administration, probiotics, prebiotics, and fecal microbiota transplantation.
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Affiliation(s)
- Zaker I. Schwabkey
- Department of Genomic Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Robert R. Jenq
- Department of Genomic Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA,Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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17
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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: 12] [Impact Index Per Article: 2.4] [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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18
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Mullane KM, Winston DJ, Nooka A, Morris MI, Stiff P, Dugan MJ, Holland H, Gregg K, Adachi JA, Pergam SA, Alexander BD, Dubberke ER, Broyde N, Gorbach SL, Sears PS. A Randomized, Placebo-controlled Trial of Fidaxomicin for Prophylaxis of Clostridium difficile-associated Diarrhea in Adults Undergoing Hematopoietic Stem Cell Transplantation. Clin Infect Dis 2019; 68:196-203. [PMID: 29893798 PMCID: PMC6321849 DOI: 10.1093/cid/ciy484] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 06/05/2018] [Indexed: 12/18/2022] Open
Abstract
Background Clostridium difficile-associated diarrhea (CDAD) is common during hematopoietic stem-cell transplantation (HSCT) and is associated with increased morbidity and mortality. We evaluated fidaxomicin for prevention of CDAD in HSCT patients. Methods In this double-blind study, subjects undergoing HSCT with fluoroquinolone prophylaxis stratified by transplant type (autologous/allogeneic) were randomized to once-daily oral fidaxomicin (200 mg) or a matching placebo. Dosing began within 2 days of starting conditioning or fluoroquinolone prophylaxis and continued until 7 days after neutrophil engraftment or completion of fluoroquinolone prophylaxis/clinically-indicated antimicrobials for up to 40 days. The primary endpoint was CDAD incidence through 30 days after study medication. The primary endpoint analysis counted confirmed CDAD, receipt of CDAD-effective medications (for any indication), and missing CDAD assessment (for any reason, including death) as failures; this composite analysis is referred to as "prophylaxis failure" to distinguish from the pre-specified sensitivity analysis, which counted only confirmed CDAD (by toxin immunoassay or nucleic acid amplification test) as failure. Results Of 611 subjects enrolled, 600 were treated and analyzed. Prophylaxis failure was similar in fidaxomicin and placebo recipients (28.6% vs 30.8%; difference 2.2% [-5.1, 9.5], P = .278). However, most failures were due to non-CDAD events. Confirmed CDAD was lower in fidaxomicin vs placebo recipients (4.3% vs 10.7%; difference 6.4% [2.2, 10.6], P = .0014). Drug-related adverse events occurred in 15.0% of fidaxomicin recipients and 20.0% of placebo recipients. Conclusions While no difference was demonstrated between arms in the primary analysis, results of the sensitivity analysis demonstrated that fidaxomicin significantly reduced the incidence of CDAD in HSCT recipients. Clinical Trials Registration NCT01691248.
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Affiliation(s)
| | | | - Ajay Nooka
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Patrick Stiff
- Loyola University Stritch School of Medicine, Maywood, Illinois
| | | | | | - Kevin Gregg
- Division of Infectious Diseases, University of Michigan, Ann Arbor
| | - Javier A Adachi
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston
| | - Steven A Pergam
- Division of Vaccine and Infectious Disease, Fred Hutchinson Cancer Research Center, University of Washington, Seattle
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
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19
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Dubberke ER, Reske KA, Olsen MA, Bommarito K, Cleveland AA, Silveira FP, Schuster MG, Kauffman CA, Avery RK, Pappas PG, Chiller TM. Epidemiology and outcomes of Clostridium difficile infection in allogeneic hematopoietic cell and lung transplant recipients. Transpl Infect Dis 2018; 20:e12855. [PMID: 29427356 DOI: 10.1111/tid.12855] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/29/2017] [Accepted: 11/07/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a common complication of lung and allogeneic hematopoietic cell (HCT) transplant, but the epidemiology and outcomes of CDI after transplant are poorly described. METHODS We performed a prospective, multicenter study of CDI within 365 days post-allogeneic HCT or lung transplantation. Data were collected via patient interviews and medical chart review. Participants were followed weekly in the 12 weeks post-transplant and while hospitalized and contacted monthly up to 18 months post-transplantation. RESULTS Six sites participated in the study with 614 total participants; 4 enrolled allogeneic HCT (385 participants) and 5 enrolled lung transplant recipients (229 participants). One hundred and fifty CDI cases occurred within 1 year of transplantation; the incidence among lung transplant recipients was 13.1% and among allogeneic HCTs was 31.2%. Median time to CDI was significantly shorter among allogeneic HCT than lung transplant recipients (27 days vs 90 days; P = .037). CDI was associated with significantly higher mortality from 31 to 180 days post-index date among the allogeneic HCT recipients (Hazard ratio [HR] = 1.80; P = .007). There was a trend towards increased mortality among lung transplant recipients from 120 to 180 days post-index date (HR = 4.7, P = .09). CONCLUSIONS The epidemiology and outcomes of CDI vary by transplant population; surveillance for CDI should continue beyond the immediate post-transplant period.
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Affiliation(s)
- E R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - K A Reske
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - M A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - K Bommarito
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - A A Cleveland
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - F P Silveira
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA
| | - M G Schuster
- University of Pennsylvania, Philadelphia, PA, USA
| | - C A Kauffman
- VA Ann Arbor Healthcare System, University of Michigan Medical School, Ann Arbor, MI, USA
| | - R K Avery
- Johns Hopkins University, Baltimore, MD, USA
| | - P G Pappas
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - T M Chiller
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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20
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Electronically Available Comorbid Conditions for Risk Prediction of Healthcare-Associated Clostridium difficile Infection. Infect Control Hosp Epidemiol 2018; 39:297-301. [PMID: 29397800 DOI: 10.1017/ice.2018.10] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To analyze whether electronically available comorbid conditions are risk factors for Centers for Disease Control and Prevention (CDC)-defined, hospital-onset Clostridium difficile infection (CDI) after controlling for antibiotic and gastric acid suppression therapy use. PATIENTS Patients aged ≥18 years admitted to the University of Maryland Medical Center between November 7, 2015, and May 31, 2017. METHODS Comorbid conditions were assessed using the Elixhauser comorbidity index. The Elixhauser comorbidity index and the comorbid condition components were calculated using the International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes extracted from electronic medical records. Bivariate associations between CDI and potential covariates for multivariable regression, including antibiotic use, gastric acid suppression therapy use, as well as comorbid conditions, were estimated using log binomial multivariable regression. RESULTS After controlling for antibiotic use, age, proton-pump inhibitor use, and histamine-blocker use, the Elixhauser comorbidity index was a significant risk factor for predicting CDI. There was an increased risk of 1.26 (95% CI, 1.19-1.32) of having CDI for each additional Elixhauser point added to the total Elixhauser score. CONCLUSIONS An increase in Elixhauser score is associated with CDI. Our study and other studies have shown that comorbid conditions are important risk factors for CDI. Electronically available comorbid conditions and scores like the Elixhauser index should be considered for risk-adjustment of CDC CDI rates. Infect Control Hosp Epidemiol 2018;39:297-301.
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