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Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev 2024; 37:e0013523. [PMID: 38421181 DOI: 10.1128/cmr.00135-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.
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Affiliation(s)
- Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Gianfranco Sanson
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - Jacopo Monticelli
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Verena Zerbato
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), Trieste, Italy
| | - Luigi Principe
- Microbiology and Virology Unit, Great Metropolitan Hospital "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Mauro Giuffrè
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
- Department of Internal Medicine (Digestive Diseases), Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Giuseppe Pipitone
- Infectious Diseases Unit, ARNAS Civico-Di Cristina Hospital, Palermo, Italy
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
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2
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Piekarska A, Sadowska-Klasa A, Mensah-Glanowska P, Sobczyk-Kruszelnicka M, Drozd-Sokołowska J, Waszczuk-Gajda A, Kujawska J, Wilk M, Tomaszewska A, Zaucha JM, Giebel S, Gil L. Effective treatment of Clostridioides difficile infection improves survival and affects graft-versus-host disease: a multicenter study by the Polish Adult Leukemia Group. Sci Rep 2024; 14:5947. [PMID: 38467719 PMCID: PMC10928209 DOI: 10.1038/s41598-024-56336-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 03/05/2024] [Indexed: 03/13/2024] Open
Abstract
Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea after allogeneic hematopoietic cell transplantation (allo-HCT). The impact of CDI and its treatment on allo-HCT outcomes and graft-versus-host disease (GVHD), including gastrointestinal GVHD (GI-GVHD) is not well established. This multicenter study assessed real-life data on the first-line treatment of CDI and its impact on allo-HCT outcomes. Retrospective and prospective data of patients with CDI after allo-HCT were assessed. We noted statistically significant increase in the incidence of acute GVHD and acute GI-GVHD after CDI (P = 0.005 and P = 0.016, respectively). The first-line treatment for CDI included metronidazole in 34 patients, vancomycin in 64, and combination therapy in 10. Treatment failure was more common with metronidazole than vancomycin (38.2% vs. 6.2%; P < 0.001). The need to administer second-line treatment was associated with the occurrence or exacerbation of GVHD (P < 0.05) and GI-GVHD (P < 0.001) and reduced overall survival (P < 0.05). In the multivariate analysis, the risk of death was associated with acute GVHD presence before CDI (hazard ratio [HR], 3.19; P = 0.009) and the need to switch to second-line treatment (HR, 4.83; P < 0.001). The efficacy of the initial CDI treatment affects survival and occurrence of immune-mediated GI-GVHD after allo-HCT. Therefore, agents with higher efficacy than metronidazole (vancomycin or fidaxomicin) should be administered as the first-line treatment.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdańsk and University Clinical Center, ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland.
| | - Alicja Sadowska-Klasa
- Department of Hematology and Transplantology, Medical University of Gdańsk and University Clinical Center, ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland
| | - Patrycja Mensah-Glanowska
- Department of Hematology, Jagiellonian University Collegium Medicum, University Hospital in Cracow, Cracow, Poland
| | - Małgorzata Sobczyk-Kruszelnicka
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Kujawska
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Mateusz Wilk
- Department of Hematology, University Hospital in Cracow, Cracow, Poland
| | - Agnieszka Tomaszewska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Jan M Zaucha
- Department of Hematology and Transplantology, Medical University of Gdańsk and University Clinical Center, ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
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Rees MJ, Rivalland A, Tan S, Xie M, Yong MK, Ritchie D. Non-viral pathogens of infectious diarrhoea post-allogeneic stem cell transplantation are associated with graft-versus-host disease. Ann Hematol 2024; 103:593-602. [PMID: 37926752 DOI: 10.1007/s00277-023-05526-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/26/2023] [Indexed: 11/07/2023]
Abstract
Infectious diarrhoea is common post-allogeneic haematopoietic stem-cell transplantation (alloHSCT). While the epidemiology of Clostridioides difficile infection (CDI) post-alloHSCT has been described, the impact of other diarrhoeal pathogens is uncertain. We reviewed all alloHSCT between 2017 and 2022 at a single large transplant centre; 374 patients were identified and included. The 1-year incidence of infectious diarrhoea was 23%, divided into viral (13/374, 3%), CDI (65/374, 17%) and other bacterial infections (16/374, 4%). There was a significant association between infectious diarrhoea within 1 year post-transplant and the occurrence of severe acute lower gastrointestinal graft-versus-host disease (GVHD, OR = 4.64, 95% CI 2.57-8.38, p < 0.001) and inferior GVHD-free, relapse-free survival on analysis adjusted for age, donor type, stem cell source and T-cell depletion (aHR = 1.64, 95% CI = 1.18-2.27, p = 0.003). When the classes of infectious diarrhoea were compared to no infection, bacterial (OR = 6.38, 95% CI 1.90-21.40, p = 0.003), CDI (OR = 3.80, 95% CI 1.91-7.53, p < 0.001) and multiple infections (OR = 11.16, 95% CI 2.84-43.92, p < 0.001) were all independently associated with a higher risk of severe GI GVHD. Conversely, viral infections were not (OR = 2.98, 95% CI 0.57-15.43, p = 0.20). Non-viral infectious diarrhoea is significantly associated with the development of GVHD. Research to examine whether the prevention of infectious diarrhoea via infection control measures or modulation of the microbiome reduces the incidence of GVHD is needed.
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Affiliation(s)
- Matthew J Rees
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia.
| | - Alexandra Rivalland
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia
| | - Sarah Tan
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia
| | - Mingdi Xie
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia
| | - Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Australia
- Sir Peter MacCallum, Department of Oncology, University of Melbourne, Melbourne, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Melbourne, Australia
| | - David Ritchie
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, 305 Grattan St, Melbourne, VIC, 3000, Australia
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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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5
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Ford CD, Hoda D, Lopansri BK, Parra M, Sharma P, Asch J. An Algorithm Addressing the Problem of Overdiagnoses of Clostridioides difficile Infections in Hematopoietic Stem-Cell Transplant Recipients: Effects on CDI Rates and Patient Outcomes. Transplant Cell Ther 2023:S2666-6367(23)01242-3. [PMID: 37086852 DOI: 10.1016/j.jtct.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/13/2023] [Accepted: 04/16/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Diarrhea of other causes and Clostridioides difficile colonization are common in patients hospitalized for hematopoietic stem-cell transplants (HSCT). It has been well recognized that these issues tend to decrease the specificity of stool testing for C. difficile infection (CDI). The best way to address this problem is uncertain. OBJECTIVE In September 2018, we initiated a project with the goal of addressing the apparent problem of overdiagnosis of CDIs in our HSCT population. Using the quality improvement tool Model for Improvement we introduced a C. difficile stool testing and CDI diagnosis algorithm with the aim of decreasing unnecessary inpatient CDI diagnoses and treatments. In this study we examine the effects of the algorithm. STUDY DESIGN We reviewed all HSCT admissions for the 2 years before the algorithm introduction and the 3 years following recording all stool submissions for C. difficile determination and CDI. At the close of the study, we recruited our advanced practice providers (APPs) to review all CDI following algorithm initiation and provide feedback on the ease of use of the algorithm and potential improvements to the overall process. RESULTS Stool submissions for C. difficile determination decreased from 38.0 to 20.6/1000 inpatient days (p=<0.001) and CDI from 5.5 to 2.4/1000 days (p=0.007). Patients admitted for a first allogeneic-HSCT, a first autologous-HSCT, or an HSCT readmission showed similar proportionate reductions. No detrimental effects on length of stay, overall survival, progression free survival, rates of readmission following transplant, incidence of acute graft vs. host disease, or incidence of recurrent CDI were noted following algorithm introduction. A strategy of education, monitoring/feedback, and ease of algorithm access proved effective in inducing provider compliance. APPs rated the algorithm high on ease of use. CONCLUSIONS Use of an algorithm defining criteria for C. difficile testing, diagnosis, and treatment was associated with significantly decreased CDI diagnoses on a HSCT inpatient unit without apparent adverse effects.
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Affiliation(s)
- Clyde D Ford
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA.
| | - Daanish Hoda
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
| | - Bert K Lopansri
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah 84143 USA; Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah 84105 USA
| | - Melissa Parra
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
| | - Prashant Sharma
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
| | - Julie Asch
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
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6
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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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Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute. GMS HYGIENE AND INFECTION CONTROL 2022; 17:Doc07. [PMID: 35707229 PMCID: PMC9174886 DOI: 10.3205/dgkh000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.
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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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Analysis of incidence and risk factors of the multidrug resistant gastrointestinal tract infection in children and adolescents undergoing allogeneic and autologous hematopoietic cell transplantation: a nationwide study. Ann Hematol 2021; 101:191-201. [PMID: 34674000 PMCID: PMC8720737 DOI: 10.1007/s00277-021-04681-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022]
Abstract
The aim of this multi-center study was to evaluate the incidence, clinical course, and risk factors for bacterial multidrug-resistant (MDR) gastrointestinal tract infections (GTI) among children undergoing allogeneic and autologous hematopoietic cell transplantation. A total number of 175 pediatric patients (aged 1–18 years), transplanted between January 2018 and December 2019, who were tested for bacterial colonization/infection were enrolled into this multi-center analysis. Episodes of MDR GTI occurred in 77/175 (44%) patients. In multivariate analysis for higher GTI incidence, the following factors were significant: matched-unrelated donor (MUD) transplantation, HLA mismatch, presence of graft-versus-host disease (GVHD), and gut GVHD. The most common GTI were Clostridium difficile (CDI), multidrug-resistant Enterobacteriaceae (Klebsiella pneumoniae, Escherichia coli extended-spectrum β-lactamase), and Enterococcus HLAR (high-level aminoglycoside-resistant). No MDR GTI–attributed deaths were reported. MDR GTI is a frequent complication after HCT among children, causes prolonged hospitalization, but rarely contributes to death. We identified risk factors of MDR GTI development in children, with focus on GVHD and unrelated donor and HLA mismatch. We conclude that the presence of Clostridiales plays an important anti-inflammatory homeostatic role and decreases incidence of GVHD or alleviate its course.
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Toxigenic Clostridium difficile-mediated Diarrhoea in Hematopoietic Stem Cell Transplantation In-Patients: Rapid Diagnosis and Efficient Treatment. Epidemiol Infect 2021; 149:e250. [PMID: 34372951 PMCID: PMC8697310 DOI: 10.1017/s095026882100162x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Allogenic hematopoietic stem cell transplant (HSCT) recipients are susceptible to any kind of infectious agents including Clostridium difficile. We studied 86 allogenic-HSCT patients who faced diarrhoea while receiving antibiotics. DNA from stool samples were explored for the presence of C. difficile toxin genes (tcdA; tcdB) by multiplex real-time PCR. Results showed nine toxigenic C. difficile amongst which seven were positive for both toxins and two were positive for tcdB. Six of toxigenic C. difficile organisms harbouring both toxin genes were also isolated by toxigenic culture. Clostridium difficile infection was controlled successfully with oral Metronidazole and Vancomycin in the confirmed infected patients.
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11
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Henig I, Yehudai-Ofir D, Zuckerman T. The clinical role of the gut microbiome and fecal microbiota transplantation in allogeneic stem cell transplantation. Haematologica 2021; 106:933-946. [PMID: 33241674 PMCID: PMC8017815 DOI: 10.3324/haematol.2020.247395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 08/28/2020] [Indexed: 12/26/2022] Open
Abstract
Outcomes of allogeneic hematopoietic stem cell transplantation (allo- HSCT) have improved in the recent decade; however, infections and graft-versus-host disease remain two leading complications significantly contributing to early transplant-related mortality. In past years, the human intestinal microbial composition (microbiota) has been found to be associated with various disease states, including cancer, response to cancer immunotherapy and to modulate the gut innate and adaptive immune response. In the setting of allo-HSCT, the intestinal microbiota diversity and composition appear to have an impact on infection risk, mortality and overall survival. Microbial metabolites have been shown to contribute to the health and integrity of intestinal epithelial cells during inflammation, thus mitigating graft-versus-host disease in animal models. While the cause-andeffect relationship between the intestinal microbiota and transplant-associated complications has not yet been fully elucidated, the above findings have already resulted in the implementation of various interventions aiming to restore the intestinal microbiota diversity and composition. Among others, these interventions include the administration of fecal microbiota transplantation. The present review, based on published data, is intended to define the role of the latter approach in the setting of allo-HSCT.
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Affiliation(s)
- Israel Henig
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa
| | - Dana Yehudai-Ofir
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa
| | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa.
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Anforderungen an die Infektionsprävention bei der medizinischen Versorgung von immunsupprimierten Patienten. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 64:232-264. [PMID: 33394069 PMCID: PMC7780910 DOI: 10.1007/s00103-020-03265-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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13
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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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Revolinski SL, Munoz-Price LS. Clostridium difficile in Immunocompromised Hosts: A Review of Epidemiology, Risk Factors, Treatment, and Prevention. Clin Infect Dis 2020; 68:2144-2153. [PMID: 30281082 DOI: 10.1093/cid/ciy845] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022] Open
Abstract
Clostridium difficile is a significant pathogen in healthcare today, impacting both hospitalized and community-based patients. Immunocompromised patients experience a high incidence of C. difficile infection, ranging from 6% to 33% in the hematology-oncology population and up to 23% among lung transplant recipients, and have a rate of 7.1-8.3 cases per 1000 patient-years in patients with human immunodeficiency virus (HIV). Recurrence of C. difficile infections among immunocompromised patients is also high, with rates up to 40% in both the hematology-oncology population and solid organ transplant recipients. This higher incidence of C. difficile infection and recurrence is believed to be secondary to frequent antimicrobial use, suppressed immune function, increased exposure to healthcare settings, and higher prevalence of C. difficile colonization. This review summarizes published data describing the epidemiology, risk factors for acquisition and infection, treatment, and prevention of C. difficile in hematology-oncology, solid organ transplant, and HIV-infected patients.
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Affiliation(s)
- Sara Lynn Revolinski
- Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee.,School of Pharmacy, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - L Silvia Munoz-Price
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee
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Vaughn JL, Balada-Llasat JM, Lamprecht M, Huang Y, Anghelina M, El Boghdadly Z, Bishop-Hill K, Childs R, Pancholi P, Andritsos LA. Detection of toxigenic Clostridium difficile colonization in patients admitted to the hospital for chemotherapy or haematopoietic cell transplantation. J Med Microbiol 2020; 67:976-981. [PMID: 29863458 PMCID: PMC6152365 DOI: 10.1099/jmm.0.000774] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Increasing evidence suggests that asymptomatic carriers are an important source of healthcare-associated Clostridium difficile infection. However, it is not known which test for the detection of C. difficile colonization is most sensitive in patients with haematological malignancies. We performed a prospective cohort study of 101 patients with haematological malignancies who had been admitted to the hospital for scheduled chemotherapy or haematopoietic cell transplantation. Each patient provided a formed stool sample. We compared the performance of five different commercially available assays, using toxigenic culture as the reference method. The prevalence of toxigenic C. difficile colonization as determined by toxigenic culture was 14/101 (14 %). The Cepheid Xpert PCR C. difficile/Epi was the most sensitive test for the detection of toxigenic C. difficile colonization, with 93 % sensitivity and 99 % negative predictive value. Our findings suggest that the Xpert PCR C. difficile/Epi could be used to rule out toxigenic C. difficile colonization in this population.
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Affiliation(s)
- John L Vaughn
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Misty Lamprecht
- Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ying Huang
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mirela Anghelina
- Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Zeinab El Boghdadly
- Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Karen Bishop-Hill
- Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rachel Childs
- Nursing Research, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Preeti Pancholi
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Leslie A Andritsos
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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A Single-Center Experience and Literature Review of Management Strategies for Clostridium difficile Infection in Hematopoietic Stem Cell Transplant Patients. ACTA ACUST UNITED AC 2019; 28:10-15. [PMID: 33424210 DOI: 10.1097/ipc.0000000000000798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction The aim of our study is to evaluate risk factors associated with the development of C. difficile infection (CDI) in hematopoietic stem cell transplant (HSCT) patients, determine its incidence and report outcomes of CDI in our patient population. Methods We performed a retrospective review of medical records of adult HSCT recipients diagnosed between 2013 and 2016 at our center. Logistic regression models were used to determine the relationship between risk factors and the odds of CDI. Results The overall incidence of CDI in HSCT patients was 9.4%. The incidence of CDI was higher in allogeneic HSCT (20%) versus autologous HSCT (4.8%). No statistically significant differences in age, gender, cancer type, transplant type were found between those who developed CDI and those who did not. However, patients with CDI had a longer length of stay (25 days) and used more antibiotics (30 days prior to and during admission for HSCT) than non-CDI patients (19 days). Only two of 17 patients (11.8%) with CDI experienced recurrence among 180 patients after HSCT. No patient suffered from toxic megacolon or ileus and no patient underwent colectomy. There was no mortality associated with CDI at our center. Conclusion CDI has an incidence rate of 9.4% in HSCT recipients. Established risk factors including age, gender, cancer type, and transplant type were not identified as risk factors in our population. However, longer LOS and use of greater than four lines of antibiotics were observed among those with CDI compared to those without CDI.
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Avni T, Babitch T, Ben-Zvi H, Hijazi R, Ayada G, Atamna A, Bishara J. Clostridioides difficile infection in immunocompromised hospitalized patients is associated with a high recurrence rate. Int J Infect Dis 2019; 90:237-242. [PMID: 31672656 DOI: 10.1016/j.ijid.2019.10.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/20/2019] [Accepted: 10/22/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Clostridioides difficile infection (CDI) may pose a serious threat to immunocompromised patients (IMC). Herein, we evaluated the clinical outcomes of IMC patients with CDI. METHODS All consecutive hospitalized patients between January 1, 2013 and December 31, 2018 with laboratory confirmed CDI were included in the study. Subjects were divided into two groups: IMC patients and controls. Primary outcome was the recurrence rate of CDI (rCDI) at 30 and 90 days after the first CDI episode. Secondary outcomes included 30 and 90 day all-cause mortality, length of hospital stay (LOS) and readmission rates. A multivariate analysis adjusted other risk factors for recurrence. An analysis of IMC patient subgroups (based on type of IMC conditions) was also performed. Results are reported as odds ratios (OR) with a 95% confidence interval (95% CI). RESULTS A total of 573 patients were included, amongst them 149 IMC patients (36 solid organ transplants, 38 undergoing chemotherapy, 62 haematological conditions, 13 receiving high dose prednisone) and 424 controls. IMC patients were younger, independent and exhibited less significant comorbidities. On multivariable analysis, the rate of rCDI was significantly higher in IMC patients (OR 2.7, 95% CI 1.6-5). rCDI was also associated with vancomycin therapy, haemodialysis and previous hospitalizations. Mortality, LOS, CDI complications and rehospitalization rates were similar in both. CONCLUSIONS IMC patients with CDI have an increased risk of 90 days rCDI. Vancomycin treatment for CDI endangers recurrence in IMC patients. Further research should explore other therapies for IMC patients with CDI with alternative agents such as Fidaxomicin and Bezlotoxumab.
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Affiliation(s)
- Tomer Avni
- Infectious Disease Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Internal Medicine Department E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Tanya Babitch
- Internal Medicine Department E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Haim Ben-Zvi
- Clinical Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Rabab Hijazi
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Gida Ayada
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Alaa Atamna
- Infectious Disease Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.
| | - Jihad Bishara
- Infectious Disease Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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Clostridium Difficile infections in patients with AML or MDS undergoing allogeneic hematopoietic stem cell transplantation identify high risk for adverse outcome. Bone Marrow Transplant 2019; 55:367-375. [PMID: 31534193 DOI: 10.1038/s41409-019-0678-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/11/2019] [Accepted: 08/09/2019] [Indexed: 12/26/2022]
Abstract
Clostridium difficile (CD) infection is the main cause of nosocomial enterocolitis in western countries and in patients undergoing allogeneic hematopoietic stem cell transplantation (alloHCT). Recipients of alloHCT are at high risk for CD infection but large studies in this population are rare and conflicting results have been reported. We analyzed 727 patients with AML or MDS undergoing alloHCT in our center from 2004 to 2015. Ninety-six patients (13%) had CD infection and 103 patients (14%) were identified as asymptomatic carriers by screening at admission and once a week during aplasia. Patients with CD infection had a shorter median overall survival of 8 months (95% CI, 6-36 months) compared with 25 months (95% CI, 17-35 months) for patients without CD infection, (HR 1.4, p = 0.04). CD positive patients were less likely to develop acute graft-versus-host disease (aGvHD; HR 0.6, p = 0.004) compared with CD-negative patients, but did not show differences in gastrointestinal aGvHD (HR 0.9, p = 0.5). Symptomatic patients developed gastrointestinal aGvHD (HR 2.5, p = 0.02) more often compared with asymptomatic CD positive patients. This analysis demonstrates a high prevalence for CD infection in patients undergoing alloHCT. A significant lower overall survival for patients with CD infection could be demonstrated.
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Intensity of Therapy for Malignancy and Risk for Recurrent and Complicated Clostridium difficile Infection in Children. J Pediatr Hematol Oncol 2019; 41:442-447. [PMID: 30664104 PMCID: PMC6635100 DOI: 10.1097/mph.0000000000001411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clostridium difficile infection (CDI) is common in pediatric oncology patients and is often associated with recurrences and complications. We hypothesized that higher intensity of chemotherapy would be associated with these outcomes. We conducted a retrospective cohort study including all cases of primary CDI in children with malignancy in our institution for over 7 years. Intensity of chemotherapy was measured by the Intensity of Treatment Rating Scale, third edition, ranging from level 1 (minimal) to 4 (highest). Outcomes included recurrence within both 56 and 180 days, CDI-associated complications, and primary treatment failure (PTF). Risk of recurrence was compared using Cox proportional hazards regression. Among 192 patients with CDI and malignancy, 122 met inclusion criteria. CDI recurred in 27% (31/115) of patients followed for 56 days and 46% (48/104) of patients followed for 180 days. Fourteen patients (11.4%) had a CDI-associated complication, including 4 intensive care unit admissions and 3 surgical procedures, but no deaths. Ten patients (8.2%) had PTF. Although PTF and severe complications were infrequent, recurrence was common in our cohort. None of these outcomes were associated with level of treatment intensity. More research is required to assess oncologic and nononcologic risk factors for CDI recurrence, PTF, and severe CDI-associated complications.
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20
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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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Kumari R, Palaniyandi S, Hildebrandt GC. Microbiome: An Emerging New Frontier in Graft-Versus-Host Disease. Dig Dis Sci 2019; 64:669-677. [PMID: 30523482 DOI: 10.1007/s10620-018-5369-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/07/2018] [Indexed: 12/12/2022]
Abstract
Hematopoietic cell transplantation is an intensive therapy used to treat high-risk hematological malignant disorders and other life-threatening hematological and genetic diseases. Graft-versus-host disease (GVHD) presents a barrier to its wider application. A conditioning regimen and medications given to patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HCT) are capable of disturbing the homeostatic crosstalk between the microbiome and the host immune system and of leading to dysbiosis. Intestinal inflammation in the context of GVHD is associated with loss in microbial diversity that could serve as an independent predictor of mortality. Successful gastrointestinal decontamination using high doses of non-absorbable antibiotics likely affect allo-HCT outcomes leading to significantly less acute GVHD (aGVHD). Butyrate-producing Clostridia directly result in the increased presence of regulatory T cells in the gut, which are protective in GVHD development. Beyond the microbiome, Candida, a member of the mycobiome, colonization in the gut has been considered as a risk factor in pathophysiology of aGVHD and reduction in GVHD is observed with antifungal prophylaxis with fluconazole. Reduced number of goblet cells and Paneth cells have been shown to associate with GVHD and has a significant impact on the micro- and mycobiome density and their composition. Lower levels of 3-indoxyl sulfate at initial stages after allo-HCT are related with worse GVHD outcomes and increased mortality. Increased understanding of the vital role of the gut microbiome in GVHD can give directions to move the field towards the development of improved innovative approaches for preventing or treating GVHD following allo-HCT.
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Affiliation(s)
- Reena Kumari
- Division of Hematology & Blood and Marrow Transplantation, Markey Cancer Center, University of Kentucky, 900 S. Limestone, Lexington, KY, 40536-0093, USA
| | - Senthilnathan Palaniyandi
- Division of Hematology & Blood and Marrow Transplantation, Markey Cancer Center, University of Kentucky, 900 S. Limestone, Lexington, KY, 40536-0093, USA
| | - Gerhard Carl Hildebrandt
- Division of Hematology & Blood and Marrow Transplantation, Markey Cancer Center, University of Kentucky, 900 S. Limestone, Lexington, KY, 40536-0093, USA. .,Department of Microbiology, Immunology & Molecular Genetics, University of Kentucky, 800 Rose Street, Lexington, KY, 40536-0093, USA.
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Abu-Sbeih H, Ali FS, Wang Y. Clinical Review on the Utility of Fecal Microbiota Transplantation in Immunocompromised Patients. Curr Gastroenterol Rep 2019; 21:8. [PMID: 30815766 DOI: 10.1007/s11894-019-0677-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Fecal microbiota transplantation (FMT) represents a promising management modality for Clostridium difficile infection (CDI). In immunocompromised patients, FMT is utilized for CDI as well as emerging non-CDI indications such as inflammatory bowel disease and graft versus host disease. PURPOSE OF REVIEW: This review aims to shed light on the safety and efficacy of FMT in immunocompromised patients, including patients suffering for human immunodeficiency virus infection, solid organ and hematopoietic stem cell transplant recipients, cancer patients, and patients on immunosuppressive therapies. RECENT FINDINGS: Though the body of evidence concerning the use of FMT in immunocompromised is growing, no clinical trials exist to date. Present literature weighs in favor of FMT in immunocompromised patients, with an acceptable adverse effect profile and minimal risk of infectious adverse events. Further large scale studies and randomized controlled trials to validate the utility of FMT in immunocompromised individuals will be a welcomed endeavor.
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Affiliation(s)
- Hamzah Abu-Sbeih
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030, USA
| | - Faisal S Ali
- Department of Internal Medicine, Presence Saint Joseph Hospital, Chicago, IL, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030, USA.
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Ilett EE, Helleberg M, Reekie J, Murray DD, Wulff SM, Khurana MP, Mocroft A, Daugaard G, Perch M, Rasmussen A, Sørensen SS, Gustafsson F, Frimodt-Møller N, Sengeløv H, Lundgren J. Incidence Rates and Risk Factors of Clostridioides difficile Infection in Solid Organ and Hematopoietic Stem Cell Transplant Recipients. Open Forum Infect Dis 2019; 6:ofz086. [PMID: 30949533 PMCID: PMC6441586 DOI: 10.1093/ofid/ofz086] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 02/15/2019] [Indexed: 12/28/2022] Open
Abstract
Background Transplant recipients are an immunologically vulnerable patient group and are at elevated risk of Clostridioides difficile infection (CDI) compared with other hospitalized populations. However, risk factors for CDI post-transplant are not fully understood. Methods Adults undergoing solid organ (SOT) and hematopoietic stem cell transplant (HSCT) from January 2010 to February 2017 at Rigshospitalet, University of Copenhagen, Denmark, were retrospectively included. Using nationwide data capture of all CDI cases, the incidence and risk factors of CDI were assessed. Results A total of 1687 patients underwent SOT or HSCT (1114 and 573, respectively), with a median follow-up time (interquartile range) of 1.95 (0.52–4.11) years. CDI was diagnosed in 15% (164) and 20% (114) of the SOT and HSCT recipients, respectively. CDI rates were highest in the 30 days post-transplant for both SOT and HSCT (adjusted incidence rate ratio [aIRR], 6.64; 95% confidence interval [CI], 4.37–10.10; and aIRR, 2.85; 95% CI, 1.83–4.43, respectively, compared with 31–180 days). For SOT recipients, pretransplant CDI and liver and lung transplant were associated with a higher risk of CDI in the first 30 days post-transplant, whereas age and liver transplant were risk factors in the later period. Among HSCT recipients, myeloablative conditioning and a higher Charlson Comorbidity Index were associated with a higher risk of CDI in the early period but not in the late period. Conclusions Using nationwide data, we show a high incidence of CDI among transplant recipients. Importantly, we also find that risk factors can vary relative to time post-transplant.
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Affiliation(s)
- Emma E Ilett
- PERSIMUNE Centre of Excellence, Rigshospitalet, Copenhagen, Denmark
| | - Marie Helleberg
- PERSIMUNE Centre of Excellence, Rigshospitalet, Copenhagen, Denmark
| | - Joanne Reekie
- PERSIMUNE Centre of Excellence, Rigshospitalet, Copenhagen, Denmark
| | - Daniel D Murray
- PERSIMUNE Centre of Excellence, Rigshospitalet, Copenhagen, Denmark
| | - Signe M Wulff
- PERSIMUNE Centre of Excellence, Rigshospitalet, Copenhagen, Denmark
| | - Mark P Khurana
- PERSIMUNE Centre of Excellence, Rigshospitalet, Copenhagen, Denmark
| | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London, London, UK
| | | | - Michael Perch
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Henrik Sengeløv
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - Jens Lundgren
- PERSIMUNE Centre of Excellence, Rigshospitalet, Copenhagen, Denmark
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Kamboj M, Brite J, Aslam A, Kennington J, Babady NE, Calfee D, Furuya Y, Chen D, Augenbraun M, Ostrowsky B, Patel G, Mircescu M, Kak V, Tuma R, Karre TA, Fry DA, Duhaney YP, Moyer A, Mitchell D, Cantu S, Hsieh C, Warren N, Martin S, Willson J, Dickman J, Knight J, Delahanty K, Flood A, Harrington J, Korenstein D, Eagan J, Sepkowitz K. Artificial Differences in Clostridium difficile Infection Rates Associated with Disparity in Testing. Emerg Infect Dis 2019; 24:584-587. [PMID: 29460760 PMCID: PMC5823336 DOI: 10.3201/eid2403.170961] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In 2015, Clostridium difficile testing rates among 30 US community, multispecialty, and cancer hospitals were 14.0, 16.3, and 33.9/1,000 patient-days, respectively. Pooled hospital onset rates were 0.56, 0.84, and 1.57/1,000 patient-days, respectively. Higher testing rates may artificially inflate reported rates of C. difficile infection. C. difficile surveillance should consider testing frequency.
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Febrile Neutropenia in Transplant Recipients. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7122322 DOI: 10.1007/978-1-4939-9034-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Febrile neutropenic patients are at increased risk of developing infections. During the initial stages of neutropenia, most of these infections are bacterial. The spectrum of bacterial infections depends to some extent on whether or not patients receive antimicrobial prophylaxis when neutropenic. Since most transplant recipients do, Gram-positive organisms predominate, due to the fact prophylaxis is directed primarily against Gram-negative organisms. Staphylococcus species (often methicillin-resistant), Streptococcus species (viridans group streptococci, beta-hemolytic streptococci), and Enterococcus species (including vancomycin-resistant strains) are isolated most often. Therefore, potent empiric Gram-positive coverage is recommended by many in this setting. Escherichia coli, Pseudomonas aeruginosa, and Klebsiella species are the most common Gram-negative pathogens isolated. Non-fermentative Gram-negative bacilli (Stenotrophomonas maltophilia, Acinetobacter species) are emerging as important pathogens. Many of these organisms acquire multiple mechanisms of resistance that render them multidrug resistant. The administration of prompt, broad-spectrum, empiric, antimicrobial therapy is essential and is generally based on local epidemiology and susceptibility/resistance patterns. Response rate to the initial regimen is generally in the range of 75–85%. Fungal infections develop in patients with prolonged neutropenia (greater than 7–10 days). Candida species and Aspergillus species are the predominant fungal pathogens, although many other fungi are opportunistic pathogens in this setting. Fungal infections are seldom documented microbiologically or on histopathology, and the administration of empiric antifungal therapy, when such infections are suspected, is the norm. Therapy is often prolonged, and outcomes are still suboptimal. The importance of infection control and antimicrobial stewardship cannot be overemphasized.
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Salamonowicz M, Ociepa T, Frączkiewicz J, Szmydki-Baran A, Matysiak M, Czyżewski K, Wysocki M, Gałązka P, Zalas-Więcek P, Irga-Jaworska N, Drożyńska E, Zając-Spychała O, Wachowiak J, Gryniewicz-Kwiatkowska O, Czajńska-Deptuła A, Dembowska-Bagińska B, Chełmecka-Wiktorczyk L, Balwierz W, Bartnik M, Zielezińska K, Urasiński T, Tomaszewska R, Szczepański T, Płonowski M, Krawczuk-Rybak M, Pierlejewski F, Młynarski W, Gamrot-Pyka Z, Woszczyk M, Małas Z, Badowska W, Urbanek-Dądela A, Karolczyk G, Stolpa W, Sobol-Milejska G, Zaucha-Prażmo A, Kowalczyk J, Goździk J, Gorczyńska E, Jermakow K, Król A, Chybicka A, Ussowicz M, Kałwak K, Styczyński J. Incidence, course, and outcome of Clostridium difficile infection in children with hematological malignancies or undergoing hematopoietic stem cell transplantation. Eur J Clin Microbiol Infect Dis 2018; 37:1805-1812. [PMID: 29978303 PMCID: PMC6133038 DOI: 10.1007/s10096-018-3316-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 06/26/2018] [Indexed: 12/13/2022]
Abstract
Clostridium difficile infection (CDI) is one of the most common causes of nosocomial infectious diarrhea in children during anticancer therapy or undergoing hematopoietic stem cell transplantation (HSCT) in Europe. Immunosuppression in these patients is a risk factor for CDI. Malignant diseases, age, acute graft-versus-host disease (aGVHD), HLA mismatch, or use of total body irradiation may play an important role in CDI course. The aim of this study was to evaluate the incidence, course, and outcome of CDI in children treated for malignancy or undergoing HSCT. Between 2012 and 2015, a total number of 1846 patients were treated for malignancy in Polish pediatric oncological centers (PHO group) and 342 underwent transplantation (HSCT group). In PHO group, episodes of CDI occurred in 210 patients (14%). The incidence of CDI was higher in patients with hematological malignancies in comparison to that with solid tumors. Patients with acute myeloblastic leukemia had shorter time to episode of CDI than those with acute lymphoblastic leukemia. Patients over 5 years and treated for acute leukemia had more severe clinical course of disease in PHO group. In HSCT group, CDI occurred in 29 (8%) patients. The incidence of CDI was higher in patients transplanted for acute leukemia. The recurrence rate was 14.7% in PHO and 20.7% in HSCT patients. CDI incidence was highest in patients with hematological malignancies. Most of patients experienced mild CDI. Age < 5 years and diagnosis other than acute leukemia were the positive prognostic factors influencing clinical CDI course.
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Affiliation(s)
- Małgorzata Salamonowicz
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Borowska Street 213, 50-556, Wrocław, Poland.
| | - T Ociepa
- Department of Pediatric Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - J Frączkiewicz
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Borowska Street 213, 50-556, Wrocław, Poland
| | - A Szmydki-Baran
- Department of Pediatric Hematology and Oncology, Medical University, Warszawa, Warszawa, Poland
| | - M Matysiak
- Department of Pediatric Hematology and Oncology, Medical University, Warszawa, Warszawa, Poland
| | - K Czyżewski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - M Wysocki
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - P Gałązka
- Department of Pediatric Surgery, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - P Zalas-Więcek
- Department of Microbiology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - N Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University, Gdansk, Gdansk, Poland
| | - E Drożyńska
- Department of Pediatrics, Hematology and Oncology, Medical University, Gdansk, Gdansk, Poland
| | - O Zając-Spychała
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - J Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | | | - A Czajńska-Deptuła
- Department of Oncology, Children's Memorial Health Institute, Warszawa, Poland
| | | | - L Chełmecka-Wiktorczyk
- Department of Pediatric Oncology and Hematology, University Children's Hospital, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - W Balwierz
- Department of Pediatric Oncology and Hematology, University Children's Hospital, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - M Bartnik
- Department of Pediatric Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - K Zielezińska
- Department of Pediatric Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - T Urasiński
- Department of Pediatric Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - R Tomaszewska
- Department of Pediatric Hematology and Oncology, Silesian Medical University, Zabrze, Poland
| | - T Szczepański
- Department of Pediatric Hematology and Oncology, Silesian Medical University, Zabrze, Poland
| | - M Płonowski
- Department of Pediatric Oncology and Hematology, Medical University, Bialystok, Bialystok, Poland
| | - M Krawczuk-Rybak
- Department of Pediatric Oncology and Hematology, Medical University, Bialystok, Bialystok, Poland
| | - F Pierlejewski
- Department of Pediatric Oncology, Hematology and Diabetology, Medical University, Lodz, Lodz, Poland
| | - W Młynarski
- Department of Pediatric Oncology, Hematology and Diabetology, Medical University, Lodz, Lodz, Poland
| | - Z Gamrot-Pyka
- Division of Pediatric Hematology and Oncology, Chorzow Pediatric and Oncology Center, Chorzow, Poland
| | - M Woszczyk
- Division of Pediatric Hematology and Oncology, Chorzow Pediatric and Oncology Center, Chorzow, Poland
| | - Z Małas
- Division of Pediatric Hematology and Oncology, Children Hospital, Olsztyn, Olsztyn, Poland
| | - W Badowska
- Division of Pediatric Hematology and Oncology, Children Hospital, Olsztyn, Olsztyn, Poland
| | - A Urbanek-Dądela
- Division of Pediatric Hematology and Oncology, Children Hospital, Kielce, Kielce, Poland
| | - G Karolczyk
- Division of Pediatric Hematology and Oncology, Children Hospital, Kielce, Kielce, Poland
| | - W Stolpa
- Division of Pediatric Oncology, Hematology and Chemotherapy, Department of Pediatric, Silesian Medical University, Katowice, Poland
| | - G Sobol-Milejska
- Division of Pediatric Oncology, Hematology and Chemotherapy, Department of Pediatric, Silesian Medical University, Katowice, Poland
| | - A Zaucha-Prażmo
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Lublin, Poland
| | - J Kowalczyk
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Lublin, Poland
| | - J Goździk
- Stem Cell Transplant Center, University Children's Hospital, Department of Clinical Immunology and Transplantology, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - E Gorczyńska
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Borowska Street 213, 50-556, Wrocław, Poland
| | - K Jermakow
- Department of Microbiology, Medical University, Wroclaw, Wroclaw, Poland
| | - A Król
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Borowska Street 213, 50-556, Wrocław, Poland
| | - A Chybicka
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Borowska Street 213, 50-556, Wrocław, Poland
| | - M Ussowicz
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Borowska Street 213, 50-556, Wrocław, Poland
| | - K Kałwak
- Department of Pediatric Stem Cell Transplantation, Hematology and Oncology, Medical University, Wroclaw, Borowska Street 213, 50-556, Wrocław, Poland
| | - J Styczyński
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
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Prohaska L, Mahmoudjafari Z, Shune L, Singh A, Lin T, Abhyankar S, Ganguly S, Grauer D, McGuirk J, Clough L. Retrospective evaluation of fidaxomicin versus oral vancomycin for treatment of Clostridium difficile infections in allogeneic stem cell transplant. Hematol Oncol Stem Cell Ther 2018; 11:233-240. [PMID: 29928848 DOI: 10.1016/j.hemonc.2018.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 03/17/2018] [Accepted: 05/12/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE/BACKGROUND Clostridium difficile infection (CDI) is a potential complication during hematopoietic stem cell transplantation (HSCT), and no specific recommendations exist regarding treatment of CDI in allogeneic SCT patients. Use of metronidazole and oral vancomycin has been associated with clinical failure. Fidaxomicin has previously been found noninferior to the use of oral vancomycin for the treatment of CDI, and no studies have compared the use of oral vancomycin with fidaxomicin for the treatment of CDI in allogeneic SCT. METHODS This retrospective chart review included 96 allogeneic SCT recipients who developed CDI within 100 days following transplantation. Participants were treated with oral vancomycin (n = 52) or fidaxomicin (n = 44). The primary outcome was clinical cure, defined as no need for further retreatment 2 days following completion of initial CDI treatment. Secondary outcomes were global cure, treatment failure, and recurrent disease. RESULTS No differences in clinical cure were observed between patients receiving oral vancomycin or fidaxomicin (75% vs. 75%, p = 1.00). Secondary outcomes were similar between oral vancomycin and fidaxomicin in regards to global cure (66% vs. 67%, p = .508), treatment failure (28% vs. 27%, p = .571), and recurrent disease (7% vs. 5%, p = .747). In a subanalysis of individuals that developed acute graft-versus-host disease following CDI, the difference in mean onset of acute graft-versus-host disease was 21.03 days in the oral vancomycin group versus 32.88 days in the fidaxomicin group (p = .0031). CONCLUSION The findings of this study suggest that oral vancomycin and fidaxomicin are comparable options for CDI treatment in allogeneic SCT patients within 100 days following transplant.
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Affiliation(s)
- Laura Prohaska
- Department of Pharmacy, University of Kansas Hospital, Kansas City, KS, USA.
| | | | - Leyla Shune
- University of Kansas Hospital, Kansas City, KS, USA; University of Kansas School of Medicine, Kansas City, KS, USA
| | - Anurag Singh
- University of Kansas Hospital, Kansas City, KS, USA; University of Kansas School of Medicine, Kansas City, KS, USA
| | - Tara Lin
- University of Kansas Hospital, Kansas City, KS, USA; University of Kansas School of Medicine, Kansas City, KS, USA
| | - Sunil Abhyankar
- University of Kansas Hospital, Kansas City, KS, USA; University of Kansas School of Medicine, Kansas City, KS, USA
| | - Siddhartha Ganguly
- University of Kansas Hospital, Kansas City, KS, USA; University of Kansas School of Medicine, Kansas City, KS, USA
| | - Dennis Grauer
- Department of Pharmacy Practice, University of Kansas School of Pharmacy, Lawrence, KS, USA
| | - Joseph McGuirk
- University of Kansas Hospital, Kansas City, KS, USA; University of Kansas School of Medicine, Kansas City, KS, USA
| | - Lisa Clough
- University of Kansas Hospital, Kansas City, KS, USA; University of Kansas School of Medicine, Kansas City, KS, USA
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Abstract
PURPOSE OF REVIEW The review summarizes the epidemiology, risk factors, clinical presentation, diagnosis and management of the most important etiologic agents of infectious diarrhea in critically ill transplant recipients. RECENT FINDINGS Diarrhea, frequently caused by infectious pathogens, can cause significant morbidity and mortality in transplant recipients. Diarrhea can lead to severe dehydration, acute renal failure, medication toxicity, rejection, graft-versus-host disease and impairs patients' quality of life. Opportunistic infectious pathogens can pose significant diagnostic and therapeutic challenges in immunocompromised hosts. SUMMARY In transplant recipients, it is vital to differentiate infectious from noninfectious diarrhea to adequately manage their therapeutic approach. Supportive measures and reduction in immunosuppression are essential for the treatment management.
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Abstract
Allogeneic haematopoietic stem cell transplantation (allo-HSCT) is considered to be the strongest curative immunotherapy for various malignancies (primarily, but not limited to, haematologic malignancies). However, application of allo-HSCT is limited owing to its life-threatening major complications, such as graft-versus-host disease (GVHD), relapse and infections. Recent advances in large-scale DNA sequencing technology have facilitated rapid identification of the microorganisms that make up the microbiota and evaluation of their interactions with host immunity in various diseases, including cancer. This has resulted in renewed interest regarding the role of the intestinal flora in patients with haematopoietic malignancies who have received an allo-HSCT and in whether the microbiota affects clinical outcomes, including GVHD, relapse, infections and transplant-related mortality. In this Review, we discuss the potential role of intestinal microbiota in these major complications after allo-HSCT, summarize clinical trials evaluating the microbiota in patients who have received allo-HSCT and discuss how further studies of the microbiota could inform the development of strategies that improve outcomes of allo-HSCT.
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Affiliation(s)
- Yusuke Shono
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, New York, USA
| | - Marcel R. M. van den Brink
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Medical College of Cornell University, New York, New York, USA
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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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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31
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Faiman B. Disease and Symptom Care: A Focus on Specific Needs of Patients With Multiple Myeloma. Clin J Oncol Nurs 2017; 21:3-6. [PMID: 28945733 DOI: 10.1188/17.cjon.s5.3-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with multiple myeloma (MM) often deal with short- and long-term side effects of the treatment and disease sequelae. Reasons for inadequately managed symptoms are multifactorial (e.g., the patient may fear treatment interruption, the clinician does not assess or address the symptoms) and can affect patients' ability to remain on the recommended treatment. This article provides background surrounding this supplement's development and describes the importance of symptom assessment and management.
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Faiman B, Doss D, Colson K, Mangan P, King T, Tariman J, Board A. Renal, GI, and Peripheral Nerves: Evidence-Based Recommendations for the Management of Symptoms and Care for Patients With Multiple Myeloma. Clin J Oncol Nurs 2017; 21:19-36. [DOI: 10.1188/17.cjon.s5.19-36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Pathogenicity Locus, Core Genome, and Accessory Gene Contributions to Clostridium difficile Virulence. mBio 2017; 8:mBio.00885-17. [PMID: 28790208 PMCID: PMC5550754 DOI: 10.1128/mbio.00885-17] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Clostridium difficile is a spore-forming anaerobic bacterium that causes colitis in patients with disrupted colonic microbiota. While some individuals are asymptomatic C. difficile carriers, symptomatic disease ranges from mild diarrhea to potentially lethal toxic megacolon. The wide disease spectrum has been attributed to the infected host’s age, underlying diseases, immune status, and microbiome composition. However, strain-specific differences in C. difficile virulence have also been implicated in determining colitis severity. Because patients infected with C. difficile are unique in terms of medical history, microbiome composition, and immune competence, determining the relative contribution of C. difficile virulence to disease severity has been challenging, and conclusions regarding the virulence of specific strains have been inconsistent. To address this, we used a mouse model to test 33 clinical C. difficile strains isolated from patients with disease severities ranging from asymptomatic carriage to severe colitis, and we determined their relative in vivo virulence in genetically identical, antibiotic-pretreated mice. We found that murine infections with C. difficile clade 2 strains (including multilocus sequence type 1/ribotype 027) were associated with higher lethality and that C. difficile strains associated with greater human disease severity caused more severe disease in mice. While toxin production was not strongly correlated with in vivo colonic pathology, the ability of C. difficile strains to grow in the presence of secondary bile acids was associated with greater disease severity. Whole-genome sequencing and identification of core and accessory genes identified a subset of accessory genes that distinguish high-virulence from lower-virulence C. difficile strains. Clostridium difficile is an important cause of hospital-associated intestinal infections, and recent years have seen an increase in the number and severity of cases in the United States. A patient’s antibiotic history, immune status, and medical comorbidities determine, in part, the severity of C. difficile infection. The relative virulence of different clinical C. difficile strains, although postulated to determine disease severity in patients, has been more difficult to consistently associate with mild versus severe colitis. We tested 33 distinct clinical C. difficile isolates for their ability to cause disease in genetically identical mice and found that C. difficile strains belonging to clade 2 were associated with higher mortality. Differences in survival were not attributed to differences in toxin production but likely resulted from the distinct gene content in the various clinical isolates.
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Lewis BB, Pamer EG. Microbiota-Based Therapies for Clostridium difficile and Antibiotic-Resistant Enteric Infections. Annu Rev Microbiol 2017; 71:157-178. [PMID: 28617651 DOI: 10.1146/annurev-micro-090816-093549] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Bacterial pathogens are increasingly antibiotic resistant, and development of clinically effective antibiotics is lagging. Curing infections increasingly requires antimicrobials that are broader spectrum, more toxic, and more expensive, and mortality attributable to antibiotic-resistant pathogens is rising. The commensal microbiota, comprising microbes that colonize the mammalian gastrointestinal tract, can provide high levels of resistance to infection, and the contributions of specific bacterial species to resistance are being discovered and characterized. Microbiota-mediated mechanisms of colonization resistance and pathogen clearance include bactericidal activity, nutrient depletion, immune activation, and manipulation of the gut's chemical environment. Current research is focusing on development of microbiota-based therapies to reduce intestinal colonization with antibiotic-resistant pathogens, with the goal of reducing pathogen transmission and systemic dissemination.
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Affiliation(s)
- Brittany B Lewis
- Infectious Diseases Service, Immunology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065; ,
| | - Eric G Pamer
- Infectious Diseases Service, Immunology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065; ,
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35
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Lee YJ, Arguello ES, Jenq RR, Littmann E, Kim GJ, Miller LC, Ling L, Figueroa C, Robilotti E, Perales MA, Barker JN, Giralt S, van den Brink MRM, Pamer EG, Taur Y. Protective Factors in the Intestinal Microbiome Against Clostridium difficile Infection in Recipients of Allogeneic Hematopoietic Stem Cell Transplantation. J Infect Dis 2017; 215:1117-1123. [PMID: 28498996 DOI: 10.1093/infdis/jix011] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is a frequent complication in recipients of allogeneic hematopoietic stem cell transplantation (allo-HSCT), who receive intensive treatments that significantly disrupt the intestinal microbiota. In this study, we examined the microbiota composition of allo-HSCT recipients to identify bacterial colonizers that confer protection against CDI after engraftment. Methods Feces collected from adult recipients allo-HSCT at engraftment were analyzed; 16S ribosomal RNA genes were sequenced and analyzed from each sample. Bacterial taxa with protective effects against development of CDI were identified by means of linear discriminant analysis effect size analysis and then further assessed with clinical predictors of CDI using survival analysis. Results A total of 234 allo-HSCT recipients were studied; postengraftment CDI developed in 53 (22.6%). Within the composition of the microbiota, the presence of 3 distinct bacterial taxa was correlated with protection against CDI: Bacteroidetes, Lachnospiraceae, and Ruminococcaceae. Colonization with these groups at engraftment was associated with a 60% lower risk of CDI, independent of clinical factors. Conclusions Colonization with these 3 bacterial groups is associated with a lower risk of CDI. These groups have been shown to be vital components of the intestinal microbiota. Targeted efforts to maintain them may help minimize the risk of CDI in this at-risk population.
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Affiliation(s)
- Yeon Joo Lee
- Infectious Diseases Service and.,Weill Cornell Medical College, New York, New York
| | | | - Robert R Jenq
- Adult Bone Marrow Transplantation Service, Department of Medicine, and.,Weill Cornell Medical College, New York, New York
| | - Eric Littmann
- Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan-Kettering Cancer Center
| | - Grace J Kim
- Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan-Kettering Cancer Center
| | - Liza C Miller
- Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan-Kettering Cancer Center
| | - Lilan Ling
- Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan-Kettering Cancer Center
| | - Cesar Figueroa
- Infectious Diseases Service and.,Weill Cornell Medical College, New York, New York
| | - Elizabeth Robilotti
- Infectious Diseases Service and.,Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, and.,Weill Cornell Medical College, New York, New York
| | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, and.,Weill Cornell Medical College, New York, New York
| | - Sergio Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, and.,Weill Cornell Medical College, New York, New York
| | - Marcel R M van den Brink
- Adult Bone Marrow Transplantation Service, Department of Medicine, and.,Weill Cornell Medical College, New York, New York
| | - Eric G Pamer
- Infectious Diseases Service and.,Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan-Kettering Cancer Center.,Immunology Program, Sloan-Kettering Institute, and.,Weill Cornell Medical College, New York, New York
| | - Ying Taur
- Infectious Diseases Service and.,Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan-Kettering Cancer Center.,Weill Cornell Medical College, New York, New York
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36
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Abstract
Diarrhea constitutes a frequent and often debilitating complication of allogeneic hematopoietic cell transplantation (alloHCT). Especially when accompanied by jaundice, skin rash, and symptoms of the upper gastrointestinal tract, diarrhea strongly suggests emergence of acute graft-versus-host disease (GvHD), which is a serious immune complication of the procedure, with possible fatal consequences. However, especially when diarrhea occurs as an isolated symptom, the other causes must be excluded before initiation of GvHD treatment with immune-suppressive drugs. In this article, a broad overview of the literature of different causes of diarrhea in the setting of alloHCT is provided, revealing causes and presentations different from those observed in the general population. We discuss gastrointestinal GvHD with a special focus on biomarkers, but also uncover underlying infectious: viral, bacterial, and parasitic as well as toxic causes of diarrhea. Finally, we suggest a practical algorithm of approach to patients with diarrhea after alloHCT, which may help to establish a proper diagnosis and initiate a causative treatment.
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37
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Scardina TL, Kang Martinez E, Balasubramanian N, Fox-Geiman M, Smith SE, Parada JP. Evaluation of Risk Factors for Clostridium difficile Infection in Hematopoietic Stem Cell Transplant Recipients. Pharmacotherapy 2017; 37:420-428. [PMID: 28226419 DOI: 10.1002/phar.1914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVES The primary objective was to determine the impact of hematologic malignancies and/or conditioning regimens on the risk of developing Clostridium difficile infection (CDI) in patients undergoing hematopoietic stem cell transplantation (HSCT). Secondary objectives were to determine if traditional CDI risk factors applied to patients undergoing HSCT and to determine the presence of CDI markers of severity of illness among this patient population. DESIGN Single-center retrospective case-control study. SETTING Quaternary care academic medical center. PATIENTS A total of 105 patients who underwent HSCT between December 2009 and December 2014; of these patients, 35 developed an initial episode of CDI (HSCT/CDI group [cases]), and 70 did not (controls). Controls were matched in a 2:1 ratio to cases based on age (± 10 yrs) and date of HSCT (± 6 mo). MEASUREMENTS AND MAIN RESULTS Baseline characteristics of the two groups were well balanced regarding age, sex, race, ethnicity, and type of HSCT. No significant differences in conditioning regimen, hematologic malignancy, total body irradiation received for HSCT, use of antibiotics within 60 days of HSCT, or use of prophylactic antibiotics after HSCT were noted between the two groups. Patients in the control group were 10.57 (95% confidence interval 1.24-492.75) more likely to have received corticosteroids prior to HSCT than patients in the HSCT/CDI group (p=0.01). Use of proton pump inhibitors at the time of HSCT was greater among the control group than among patients in the HSCT/CDI group (97% vs 86%, p=0.048). No significant difference in mortality was noted between the groups at 3, 6, and 12 months after HSCT. Metronidazole was frequently prescribed for patients in the HSCT/CDI group (34 patients [97%]). Severe CDI was not common among patients within the HSCT/CDI group (13 patients [37%]); vancomycin was infrequently prescribed for these patients ([31%] 4/13 patients). CONCLUSION Hematologic malignancies and a conditioning regimen administered for HSCT were not significant risk factors for the development of CDI after HSCT. Use of corticosteroids prior to HSCT and use of proton pump inhibitors at the time of HSCT were associated with a significantly decreased risk of CDI.
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Affiliation(s)
- Tonya L Scardina
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois
| | | | | | - Mary Fox-Geiman
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois
| | - Scott E Smith
- Division of Hematology/Oncology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Jorge P Parada
- Division of Infectious Diseases, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
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Risk for Clostridium difficile Infection After Allogeneic Hematopoietic Cell Transplant Remains Elevated in the Postengraftment Period. Transplant Direct 2017; 3:e145. [PMID: 28405601 PMCID: PMC5381738 DOI: 10.1097/txd.0000000000000662] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 01/31/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a frequent cause of diarrhea among allogeneic hematopoietic cell transplant (HCT) recipients. It is unknown whether risk factors for CDI vary by time posttransplant. METHODS We performed a 3-year prospective cohort study of CDI in allogeneic HCT recipients. Participants were enrolled during their transplant hospitalizations. Clinical assessments were performed weekly during hospitalizations and for 12 weeks posttransplant, and monthly for 30 months thereafter. Data were collected through patient interviews and chart review, and included CDI diagnosis, demographics, transplant characteristics, medications, infections, and outcomes. CDI cases were included if they occurred within 1 year of HCT and were stratified by time from transplant. Multivariable logistic regression was used to determine risk factors for CDI. RESULTS One hundred eighty-seven allogeneic HCT recipients were enrolled, including 63 (34%) patients who developed CDI. 38 (60%) CDI cases occurred during the preengraftment period (days 0-30 post-HCT) and 25 (40%) postengraftment (day >30). Lack of any preexisting comorbid disease was significantly associated with lower risk of CDI preengraftment (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.9). Relapsed underlying disease (OR, 6.7; 95% CI, 1.3-33.1), receipt of any high-risk antimicrobials (OR, 11.8; 95% CI, 2.9-47.8), and graft-versus-host disease (OR, 7.8; 95% CI, 2.0-30.2) were significant independent risk factors for CDI postengraftment. CONCLUSIONS A large portion of CDI cases occurred during the postengraftment period in allogeneic HCT recipients, suggesting that surveillance for CDI should continue beyond the transplant hospitalization and preengraftment period. Patients with continued high underlying severity of illness were at increased risk of CDI postengraftment.
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Slade M, Goldsmith S, Romee R, DiPersio JF, Dubberke ER, Westervelt P, Uy GL, Lawrence SJ. Epidemiology of infections following haploidentical peripheral blood hematopoietic cell transplantation. Transpl Infect Dis 2017; 19:e12629. [PMID: 28030755 PMCID: PMC5459579 DOI: 10.1111/tid.12629] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/19/2016] [Accepted: 07/25/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND The use of T-cell replete haploidentical hematopoietic cell transplant (haplo-HCT) has increased substantially since the introduction of post-transplant cyclophosphamide (PTCy) regimens. Limited data exist concerning infectious complications of haplo-HCT utilizing mobilized peripheral blood (PB) hematopoietic cells. METHODS This retrospective cohort study included all adult patients at our institution undergoing PB haplo-HCT with PTCy between June 2009 and June 2015. Infections were microbiologically confirmed. Invasive fungal infections (IFI) classified as "proven" or "probable" by standard definitions were included. RESULTS In total, 104 patients were identified. Median follow-up was 218 days (range: 6-1576). A total of 322 episodes of infection were recorded. Eighty-nine percent of patients experienced at least one infection. Median time to first infection was 22 days. Patients experiencing at least one bacterial, viral, and IFI were 62%, 72%, and 6%, respectively. The majority (69%) of bacterial infections were caused by enteric organisms. Seven cases of Staphylococcus aureus infection were recorded, with one bacteremia case. Cytomegalovirus (CMV) viremia occurred in 54/71 (76%) at-risk patients at a median time of 24 days. Sixteen (15%) patients developed CMV disease. Nineteen percent (20/104) of patients developed BK polyomavirus-associated cystitis. Six (6%) patients experienced a total of seven IFI. Infection was the primary cause of death for 12% (6/51) of patients and was a secondary cause for 41%. CONCLUSION In PB haplo-HCT patients, a high incidence of CMV viremia and disease was observed. Infections with enteric bacteria were common. Fungal and staphylococcal infections were uncommon. Further studies are needed to compare infectious complications in haplo-HCT with other transplant modalities.
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Affiliation(s)
- Michael Slade
- Department of MedicineWashington University School of MedicineSaint LouisMOUSA
| | - Scott Goldsmith
- Department of MedicineWashington University School of MedicineSaint LouisMOUSA
| | - Rizwan Romee
- Division of OncologyWashington University School of MedicineSaint LouisMOUSA
| | - John F. DiPersio
- Division of OncologyWashington University School of MedicineSaint LouisMOUSA
| | - Erik R. Dubberke
- Division of Infectious DiseasesWashington University School of MedicineSaint LouisMOUSA
| | - Peter Westervelt
- Division of OncologyWashington University School of MedicineSaint LouisMOUSA
| | - Geoffrey L. Uy
- Division of OncologyWashington University School of MedicineSaint LouisMOUSA
| | - Steven J. Lawrence
- Division of Infectious DiseasesWashington University School of MedicineSaint LouisMOUSA
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Lavallée C, Labbé AC, Talbot JD, Alonso CD, Marr KA, Cohen S, Laverdière M, Dufresne SF. Risk factors for the development of Clostridium difficile infection in adult allogeneic hematopoietic stem cell transplant recipients: A single-center study in Québec, Canada. Transpl Infect Dis 2017; 19. [PMID: 27943498 DOI: 10.1111/tid.12648] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 09/01/2016] [Accepted: 09/12/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a significant complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Our primary objective was to determine risk factors for the development of CDI during the first year following allo-HSCT. METHODS A matched case-control study nested in a cohort of allo-HSCT at a single hospital in Montréal, Québec, Canada, was conducted from 2002 through 2011. RESULTS Sixty-five of 760 patients who underwent allo-HSCT between 2002 and 2011 developed CDI, representing an incidence of 8.6%. We selected 123 controls matched for year of transplant for risk factor analyses. In the multivariable analysis, receipt of trimethoprim-sulfamethoxazole (TMP-SMX) prior to transplantation (adjusted odds ratio [aOR] 0.07, 95% confidence interval [CI] 0.02-0.27), mucositis (aOR 5.90, 95% CI 2.08-16.72), and reactivation of cytomegalovirus (CMV) (aOR 6.17, 95% CI 2.17-17.57) and of other Herpesviridae viruses (aOR 3.04, 95% CI 1.13-8.16) were the variables that remained statistically associated with CDI. High-risk antibiotic use in the late post-transplant period (aOR 7.63, 95% CI 2.14-27.22) was associated with development of late CDI. CONCLUSION This study revealed reactivation of CMV and other Herpesviridae viruses as novel risk factors for CDI. Administration of TMP-SMX prior to transplantation was independently associated with a decreased risk of CDI. Early and late CDI after HSCT may have distinct risk factors.
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Affiliation(s)
- Christian Lavallée
- Department of Infectious Diseases and Medical Microbiology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Annie-Claude Labbé
- Department of Infectious Diseases and Medical Microbiology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Jean-Daniel Talbot
- Department of Infectious Diseases and Medical Microbiology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Carolyn D Alonso
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kieren A Marr
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandra Cohen
- Division of Hematology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Michel Laverdière
- Department of Infectious Diseases and Medical Microbiology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Simon Frédéric Dufresne
- Department of Infectious Diseases and Medical Microbiology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
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Neemann K, Freifeld A. Clostridium difficile–Associated Diarrhea in the Oncology Patient. J Oncol Pract 2017; 13:25-30. [DOI: 10.1200/jop.2016.018614] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile is the most common cause of nosocomial diarrhea, resulting in significant morbidity and mortality in hospitalized patients. Oncology patients are particularly at risk of this infection secondary to frequent exposure to known risk factors. In a population in which diarrhea is a common adverse effect of chemotherapeutic regimens, diagnosis can be challenging secondary to current limitations in testing to differentiate between colonization and active infection. Although several currently available antimicrobial therapies achieve resolution of symptoms in this population, further research is needed to determine which agent least affects the host intestinal microbiota, especially in times of neutropenia and mucosal barrier injury. The purpose of this article is to review the current literature on the epidemiology, pathogenesis, and management of C difficile–associated diarrhea in the oncology population.
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Affiliation(s)
- Kari Neemann
- University of Nebraska Medical Center, Omaha, NE
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Hebbard AIT, Slavin MA, Reed C, Teh BW, Thursky KA, Trubiano JA, Worth LJ. The epidemiology of Clostridium difficile infection in patients with cancer. Expert Rev Anti Infect Ther 2016; 14:1077-1085. [PMID: 27606976 DOI: 10.1080/14787210.2016.1234376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Clostridium difficile infection (CDI) is a significant cause of healthcare-associated diarrhoea, and the emergence of endemic strains resulting in poorer outcomes is recognised worldwide. Patients with cancer are a specific high-risk group for development of infection. Areas covered: In this review, modifiable and non-modifiable risk factors for CDI in adult patients with haematological malignancy or solid tumours are evaluated. In particular, the contribution of antimicrobial exposure, hospitalisation and gastric acid suppression to risk of CDI are discussed. Recent advances in CDI treatment are outlined, namely faecal microbiota transplantation and fidaxomicin therapy for severe/refractory infection in cancer populations. Outcomes of CDI, including mortality are presented, together with the need for valid severity rating tools customised for cancer populations. Expert commentary: Future areas for research include the prognostic value of C. difficile colonisation in cancer patients and the potential impact of dedicated antimicrobial stewardship programs in reducing the burden of CDI in cancer units.
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Affiliation(s)
- Andrew I T Hebbard
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia
| | - Caroline Reed
- c Microbiology Department , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Benjamin W Teh
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Karin A Thursky
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Jason A Trubiano
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Leon J Worth
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Australia.,d Victorian Healthcare Associated Infection Surveillance System (VICNISS) , Doherty Institute , Melbourne , Australia
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Abt MC, McKenney PT, Pamer EG. Clostridium difficile colitis: pathogenesis and host defence. Nat Rev Microbiol 2016; 14:609-20. [PMID: 27573580 DOI: 10.1038/nrmicro.2016.108] [Citation(s) in RCA: 328] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Clostridium difficile is a major cause of intestinal infection and diarrhoea in individuals following antibiotic treatment. Recent studies have begun to elucidate the mechanisms that induce spore formation and germination and have determined the roles of C. difficile toxins in disease pathogenesis. Exciting progress has also been made in defining the role of the microbiome, specific commensal bacterial species and host immunity in defence against infection with C. difficile. This Review will summarize the recent discoveries and developments in our understanding of C. difficile infection and pathogenesis.
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Affiliation(s)
- Michael C Abt
- Immunology Program, Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, USA
| | - Peter T McKenney
- Immunology Program, Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, USA
| | - Eric G Pamer
- Immunology Program, Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, USA
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44
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Harris B, Morjaria SM, Littmann ER, Geyer AI, Stover DE, Barker JN, Giralt SA, Taur Y, Pamer EG. Gut Microbiota Predict Pulmonary Infiltrates after Allogeneic Hematopoietic Cell Transplantation. Am J Respir Crit Care Med 2016; 194:450-63. [PMID: 26886180 PMCID: PMC5003327 DOI: 10.1164/rccm.201507-1491oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 02/16/2016] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Pulmonary complications (PCs) cause significant morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HCT). Shifts in gut microbiota have been linked to HCT outcomes; however, their effect on PCs is unknown. OBJECTIVES To investigate whether changes in gut microbiota are associated with PCs after HCT. METHODS A single-center observational study was performed on 94 patients who underwent HCT from 2009 to 2011 and who were previously enrolled in a protocol for 16S ribosomal RNA sequencing of fecal microbiota. The primary endpoint, PC, was defined by new abnormal parenchymal findings on chest imaging in the setting of respiratory signs and/or symptoms. Outcomes were collected up to 40 months after transplant. Clinical and microbiota risk factors for PCs and mortality were evaluated using survival analysis. MEASUREMENTS AND MAIN RESULTS One hundred twelve PCs occurred in 66 (70.2%) subjects. A high comorbidity index (hazard ratio [HR], 2.30; 95% confidence interval [CI], 1.30-4.00; P = 0.004), fluoroquinolones (HR, 2.29, 95% CI, 1.32-3.98; P = 0.003), low baseline diversity (HR, 2.63; 95% CI, 1.22-5.32; P = 0.015), and γ-proteobacteria domination of fecal microbiota (HR, 2.64; 95% CI, 1.10-5.65; P = 0.031), which included common respiratory pathogens, predicted PCs. In separate analyses, low baseline diversity was associated with PCs that occurred preengraftment (HR, 6.30; 95% CI, 1.42-31.80; P = 0.016), whereas γ-proteobacteria domination predicted PCs postengraftment (HR, 3.68; 95% CI, 1.49-8.21; P = 0.006) and overall mortality (HR, 3.52; 95% CI, 1.28-9.21; P = 0.016). Postengraftment PCs were also independent predictors of death (HR, 2.50; 95% CI, 1.25-5.22; P = 0.009). CONCLUSIONS This is the first study to demonstrate prospective changes in gut microbiota associated with PCs after HCT. Postengraftment PCs and γ-proteobacteria domination were predictive of mortality. This suggests an adverse relationship between the graft and lung, which is perhaps mediated by bacterial composition in the gut. Further study is warranted.
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Affiliation(s)
| | | | - Eric R. Littmann
- Lucille Castori Center for Microbes, Inflammation and Cancer, Sloan Kettering Institute, New York, New York; and
| | - Alexander I. Geyer
- Pulmonary Service
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Diane E. Stover
- Pulmonary Service
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Juliet N. Barker
- Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sergio A. Giralt
- Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ying Taur
- Infectious Diseases Service, and
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Eric G. Pamer
- Infectious Diseases Service, and
- Lucille Castori Center for Microbes, Inflammation and Cancer, Sloan Kettering Institute, New York, New York; and
- Department of Medicine, Weill Cornell Medical College, New York, New York
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Lewis BB, Carter RA, Pamer EG. Bile acid sensitivity and in vivo virulence of clinical Clostridium difficile isolates. Anaerobe 2016; 41:32-36. [PMID: 27241781 DOI: 10.1016/j.anaerobe.2016.05.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/17/2016] [Accepted: 05/19/2016] [Indexed: 02/08/2023]
Abstract
Clostridium difficile is an anaerobic bacterium that causes diarrheal illnesses. Disease onset is linked with exposure to oral antibiotics and consequent depletion of secondary bile acids. Here we investigate the relationship between in vitro secondary bile acid tolerance and in vivo disease scores of diverse C. difficile strains in mice.
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Affiliation(s)
- Brittany B Lewis
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Immunology Programs, Sloan Kettering Institute, New York, NY, 10065, United States
| | - Rebecca A Carter
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Immunology Programs, Sloan Kettering Institute, New York, NY, 10065, United States
| | - Eric G Pamer
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Immunology Programs, Sloan Kettering Institute, New York, NY, 10065, United States.
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Abstract
Infections encountered in the cancer setting may arise from intensive cancer treatments or may result from the cancer itself, leading to risk of infections through immune compromise, disruption of anatomic barriers, and exposure to nosocomial (hospital-acquired) pathogens. Consequently, cancer-related infections are unique and epidemiologically distinct from those in other patient populations and may be particularly challenging for clinicians to treat. There is increasing evidence that the microbiome is a crucial factor in the cancer patient's risk for infectious complications. Frequently encountered pathogens with observed ties to the microbiome include vancomycin-resistant Enterococcus, Enterobacteriaceae, and Clostridium difficile; these organisms can exist in the human body without disease under normal circumstances, but all can arise as infections when the microbiome is disrupted. In the cancer patient, such disruptions may result from interventions such as chemotherapy, broad-spectrum antibiotics, or anatomic alteration through surgery. In this review, we discuss evidence of the significant role of the microbiome in cancer-related infections; how a better understanding of the role of the microbiome can facilitate our understanding of these complications; and how this knowledge might be exploited to improve outcomes in cancer patients and reduce risk of infection.
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Affiliation(s)
- Ying Taur
- Infectious Disease Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Eric G Pamer
- Infectious Disease Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
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Abstract
The number of patients undergoing hematopoietic cell and solid organ transplantation are increasing every year, as are the number of centers both transplanting and caring for these patients. Improvements in transplant procedures, immunosuppressive regimens, and prevention of transplant-associated complications have led to marked improvements in survival in both populations. Infections remain one of the most important sources of excess morbidity and mortality in transplant, and therefore, infection prevention strategies are a critical element for avoiding these complications in centers caring for high-risk patients. This manuscript aims to provide an update of recent data on prevention of major healthcare-associated infections unique to transplantation, reviews the emergence of antimicrobial resistant infections, and discusses updated strategies to both identify and prevent transmission of these pathogens in transplant recipients.
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Caimi PF. Clostridium difficile infection is a frequent but well-controlled event after hematopoietic cell transplantation. Rev Bras Hematol Hemoter 2015; 37:371-2. [PMID: 26670398 PMCID: PMC4678905 DOI: 10.1016/j.bjhh.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 09/11/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- Paolo Fabrizio Caimi
- Case Western Reserve University, Cleveland, United States; Case Comprehensive Cancer Center, Cleveland, United States.
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50
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Nicholson MR, Osgood CL, Acra SA, Edwards KM. Clostridium difficile infection in the pediatric transplant patient. Pediatr Transplant 2015; 19:792-8. [PMID: 26403484 DOI: 10.1111/petr.12578] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 12/17/2022]
Abstract
CDIs are on the rise in both hospital and community settings in adults and children. Children with cancer or a history of HSCT or SOT appear to be at higher risk for primary disease, recurrent disease, and severe outcomes when compared to children with other comorbidities. The reasons for this are not clear and no studies to date have analyzed risk factors for CDI in pediatric transplant patients. Colonization rates in children with cancer and a transplant history are also high. Determining which children are colonized with Clostridium difficile and symptomatic from another source vs. symptomatic from CDI is difficult and a clinical conundrum for the transplant physician. The use of fecal transplantation for severe or rCDI is likely safe and effective in the immunosuppressed pediatric cancer or transplant patient, but this will need to be more thoroughly studied in this patient population.
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Affiliation(s)
- Maribeth R Nicholson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christy L Osgood
- Division of Pediatric Hematology and Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sari A Acra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Kathryn M Edwards
- Division of Pediatric Infectious Disease, Vanderbilt University School of Medicine, Nashville, TN, USA
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