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Fernandez-Cotarelo MJ, Jackson-Akers JY, Nagy-Agren SE, Warren CA. Interaction of Clostridioides difficile infection with frailty and cognition in the elderly: a narrative review. Eur J Med Res 2023; 28:439. [PMID: 37849008 PMCID: PMC10580652 DOI: 10.1186/s40001-023-01432-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 10/05/2023] [Indexed: 10/19/2023] Open
Abstract
PURPOSE Clostridioides difficile infection (CDI) is the leading cause of antibiotic-related diarrhea and healthcare-associated infections, affecting in particular elderly patients and their global health. This review updates the understanding of this infection, with focus on cognitive impairment and frailty as both risk factors and consequence of CDI, summarizing recent knowledge and potential mechanisms to this interplay. METHODS A literature search was conducted including terms that would incorporate cognitive and functional impairment, aging, quality of life, morbidity and mortality with CDI, microbiome and the gut-brain axis. RESULTS Advanced age remains a critical risk for severe disease, recurrence, and mortality in CDI. Observational and quality of life studies show evidence of functional loss in older people after acute CDI. In turn, frailty and cognitive impairment are independent predictors of death following CDI. CDI has long-term impact in the elderly, leading to increased risk of readmissions and mortality even months after the acute event. Immune senescence and the aging microbiota are key in susceptibility to CDI, with factors including inflammation and exposure to luminal microbial products playing a role in the gut-brain axis. CONCLUSIONS Frailty and poor health status are risk factors for CDI in the elderly. CDI affects quality of life, cognition and functionality, contributing to a decline in patient health over time and leading to early and late mortality. Narrative synthesis of the evidence suggests a framework for viewing the cycle of functional and cognitive decline in the elderly with CDI, impacting the gut-brain and gut-muscle axes.
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Affiliation(s)
- Maria-Jose Fernandez-Cotarelo
- Department of Internal Medicine, Hospital Universitario de Mostoles, Faculty of Health Sciences, Universidad Rey Juan Carlos, Calle Doctor Luis Montes S/N, Mostoles, 28935, Madrid, Spain.
| | - Jasmine Y Jackson-Akers
- División of Infectious Disease and International Health, University of Virginia, Charlottesville, VA, USA
| | - Stephanie E Nagy-Agren
- Section of Infectious Diseases, Salem Veterans Affairs Medical Center, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Cirle A Warren
- Division of Infectious Disease and International Health, University of Virginia, Charlottesville, VA, USA
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2
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Garey KW, Dubberke ER, Guo A, Harvey A, Yang M, García-Horton V, Fillbrunn M, Wang H, Tillotson GS, Bancke LL, Feuerstadt P. Effect of Fecal Microbiota, Live-Jslm (REBYOTA [RBL]) on Health-Related Quality of Life in Patients With Recurrent Clostridioides difficile Infection: Results From the PUNCH CD3 Clinical Trial. Open Forum Infect Dis 2023; 10:ofad383. [PMID: 37564743 PMCID: PMC10411038 DOI: 10.1093/ofid/ofad383] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/18/2023] [Indexed: 08/12/2023] Open
Abstract
Background Recurrence of Clostridioides difficile infection (rCDI) is common, prolonging disease morbidity and leading to poor quality of life. We evaluated disease-specific health-related quality of life (HRQL) in patients with rCDI treated with fecal microbiota, live-jslm (REBYOTA [RBL]; Rebiotix) versus placebo. Methods This was a secondary analysis of a randomized, double-blind, placebo-controlled phase 3 study (PUNCH CD3). The disease-specific Clostridioides difficile Quality of Life Survey (Cdiff32) was administered at baseline and at weeks 1, 4, and 8. Changes in Cdiff32 total and domain (physical, mental, social) scores from baseline to week 8 were compared between RBL and placebo and for responders and nonresponders. Results Findings were analyzed in a total of 185 patients (RBL, n = 128 [69.2%]; placebo, n = 57 [30.8%]) with available Cdiff32 data. Patients from both arms showed significant improvements in Cdiff32 scores relative to baseline across all outcomes and at all time points (all P < .001); RBL-treated patients showed significantly greater improvements in mental domain than those receiving placebo. In adjusted analyses, RBL-treated patients showed greater improvements than placebo in total score and physical and mental domains (all P < .05). Similar improvement in mental domain was observed among responders, while nonresponders showed numerical improvements with RBL but not placebo. Conclusions In a phase 3 double-blinded clinical trial, RBL-treated patients reported more substantial and sustained disease-specific HRQL improvements than placebo-treated patients. Clinical Trials Registration ClinicalTrials.gov NCT03244644 (https://clinicaltrials.gov/ct2/show/NCT03244644).
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Affiliation(s)
| | | | - Amy Guo
- Ferring Pharmaceuticals, Parsippany, New Jersey, USA
| | - Adam Harvey
- Rebiotix, a Ferring Company, Roseville, Minnesota, USA
| | - Min Yang
- Analysis Group Inc., Boston, Massachusetts, USA
| | | | | | | | | | | | - Paul Feuerstadt
- Yale University School of Medicine, New Haven, Connecticut, USA
- PACT-Gastroenterology Center, New Haven, Connecticut, USA
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3
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Armstrong EP, Malone DC, Franic DM, Pham SV, Gratie D, Amin A. Patient Experiences with Clostridioides difficile Infection and Its Treatment: A Systematic Literature Review. Infect Dis Ther 2023:10.1007/s40121-023-00833-x. [PMID: 37395984 PMCID: PMC10390453 DOI: 10.1007/s40121-023-00833-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is a globally recognized cause of morbidity and mortality with devastating effects on health-related quality of life (HRQoL). The objective of this study was to conduct the first systematic literature review (SLR) to assess the humanistic burden of CDI on patient experiences, including HRQoL and related constructs, and attitudes towards treatment alternatives. METHODS An SLR was conducted to identify peer-reviewed articles that assessed CDI, including recurrent CDI (rCDI), and patient-reported outcomes or HRQoL. PubMed, Embase, and the Cochrane Collaboration abstracting services were used to conduct literature searches from 2010 to 2021 in the English language. This SLR was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. RESULTS Of 511 identified articles, 21 met study inclusion criteria. The SLR showed CDI has a devastating impact on patients' overall HRQoL that continues well beyond infection clearance. The impact of CDI on physical, emotional, social, and professional well-being rivaled abdominal symptoms of uncontrollable diarrhea, being worse for patients with rCDI. Patients with CDI feel isolated, depressed, lonely, and continue to be frightened of recurrences as well as being contagious to others. Most believe that they will never be free of CDI. CONCLUSION CDI and rCDI are debilitating conditions affecting physical, psychological, social, and professional functioning of patients' HRQoL, even long after the event has occurred. The results of this SLR suggest that CDI is a devastating condition in need of better prevention strategies, improved psychological support, and treatments that address the microbiome disruption to break the cycle of recurrence. Additional safe and effective therapies are needed to address this unmet medical need.
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Affiliation(s)
- Edward P Armstrong
- Strategic Therapeutics and University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Daniel C Malone
- Strategic Therapeutics and University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Duska M Franic
- Evidence Institute AESARA, P.O. Box 4266, Chapel Hill, NC, 27515, USA.
| | - Sissi V Pham
- Evidence Institute AESARA, P.O. Box 4266, Chapel Hill, NC, 27515, USA
| | - Dan Gratie
- Evidence Institute AESARA, P.O. Box 4266, Chapel Hill, NC, 27515, USA
| | - Alpesh Amin
- Medicine, Business, Public Health, Nursing Science, & Biomedical Engineering, Hospitalist Program, University of California, Irvine, Irvine, CA, USA
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Feuerstadt P, Theriault N, Tillotson G. The burden of CDI in the United States: a multifactorial challenge. BMC Infect Dis 2023; 23:132. [PMID: 36882700 PMCID: PMC9990004 DOI: 10.1186/s12879-023-08096-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/16/2023] [Indexed: 03/09/2023] Open
Abstract
Clostridioides difficile infection (CDI) affects approximately 500,000 patients annually in the United States, of these around 30,000 will die. CDI carries significant burdens including clinical, social and economic. While healthcare-associated CDI has declined in recent years, community-associated CDI is on the rise. Many patients are also impacted by recurrent C. difficile infections (rCDI); up to 35% of index CDI will recur and of these up to 60% will further recur with multiple recurrences observed. The range of outcomes adversely affected by rCDI is significant and current standard of care does not alter these recurrence rates due to the damaged gut microbiome and subsequent dysbiosis. The clinical landscape of CDI is changing, we discuss the impact of CDI, rCDI, and the wide range of financial, social, and clinical outcomes by which treatments should be evaluated.
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Affiliation(s)
- Paul Feuerstadt
- Division of Digestive Disease, PACT-Gastroenterology Center, Yale University School of Medicine, Hamden, CT, USA
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Hocking L, Wilcox M, Petrosillo N, Griffin P, Steiner T, Attara G, Doré J, Cabling M, Stockwell S, Romanelli RJ, Marjanovic S. Improving care for patients with Clostridioides difficile infection: A clinical practice and healthcare systems perspective. Front Med (Lausanne) 2023; 9:1033417. [PMID: 36714122 PMCID: PMC9877614 DOI: 10.3389/fmed.2022.1033417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/23/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction Arriving at a C. difficile infection (CDI) diagnosis, treating patients and dealing with recurrences is not straightforward, but a comprehensive and well-rounded understanding of what is needed to improve patient care is lacking. This manuscript addresses the paucity of multidisciplinary perspectives that consider clinical practice related and healthcare system-related challenges to optimizing care delivery. Methods We draw on narrative review, consultations with clinical experts and patient representatives, and a survey of 95 clinical and microbiology experts from the UK, France, Italy, Australia and Canada, adding novel multi-method evidence to the knowledge base. Results and discussion We examine the patient pathway and variations in clinical practice and identify, synthesize insights on and discuss associated challenges. Examples of key challenges include the need to conduct multiple tests for a conclusive diagnosis, treatment side-effects, the cost of some antibiotics and barriers to access of fecal microbiota transplantation, difficulties in distinguishing recurrence from new infection, workforce capacity constraints to effective monitoring of patients on treatment and of recurrence, and ascertaining whether a patient has been cured. We also identify key opportunities and priorities for improving patient care that target both clinical practice and the wider healthcare system. While there is some variety across surveyed countries' healthcare systems, there is also strong agreement on some priorities. Key improvement actions seen as priorities by at least half of survey respondents in at least three of the five surveyed countries include: developing innovative products for both preventing (Canada, Australia, UK, Italy, and France) and treating (Canada, Australia, and Italy) recurrences; facilitating more multidisciplinary patient care (UK, Australia, and France); updating diagnosis and treatment guidelines (Australia, Canada, and UK); and educating and supporting professionals in primary care (Italy, UK, Canada, and Australia) and those in secondary care who are not CDI experts (Italy, Australia, and France) on identifying symptoms and managing patients. Finally, we discuss key evidence gaps for a future research agenda.
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Affiliation(s)
| | - Mark Wilcox
- School of Medicine, University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Nicola Petrosillo
- Policlinico Universitario, Bio-Medico Campus University Hospital, Rome, Italy
| | - Paul Griffin
- Mater Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Theodore Steiner
- Division of Infectious Diseases, The University of British Columbia, Vancouver, BC, Canada
| | - Gail Attara
- Canadian Society of Intestinal Research, Vancouver, BC, Canada
- Gastrointestinal Society, Vancouver, BC, Canada
| | - Joel Doré
- INRAE, MetaGenoPolis, AgroParisTech, Micalis Institute, Université Paris-Saclay, Jouy-en-Josas, France
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Hengel RL, Schroeder CP, Jo J, Ritter TE, Nathan RV, Gonzales-Luna AJ, Obi EN, Dillon RJ, Van Anglen LJ, Garey KW. Recurrent Clostridioides difficile infection worsens anxiety-related patient-reported quality of life. J Patient Rep Outcomes 2022; 6:49. [PMID: 35567724 PMCID: PMC9107550 DOI: 10.1186/s41687-022-00456-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 04/29/2022] [Indexed: 12/03/2022] Open
Abstract
Background Clostridioides difficile infection (CDI) is associated with high recurrence rates impacting health-related quality of life (HrQOL). However, patient-reported data are lacking particularly in the outpatient setting. We assessed changes in HrQOL over time in patients treated with bezlotoxumab at US infusion centers and determined clinical factors associated with HrQOL changes. Methods The HrQOL survey was conducted in adult patients with CDI, who received bezlotoxumab in 25 US outpatient infusion centers. The survey was adapted from the Cdiff32 instrument to assess anxiety-related changes to HrQOL and completed on the day of infusion (baseline) and at 90 days post bezlotoxumab (follow-up). Demographics, disease history, CDI risk factors, and recurrence of CDI (rCDI) at 90-day follow-up were collected. Changes in HrQOL scores were calculated and outcomes assessed using a multivariable linear regression model with P < 0.05 defined as statistically significant. Results A total of 144 patients (mean age: 68 ± 15 years, 63% female, median Charlson index: 4, 15.9% rCDI) were included. The overall mean baseline and follow-up HrQOL scores were 26.4 ± 11.5 and 56.4 ± 25.0, respectively. At follow-up, this score was significantly higher for patients who had primary CDI (34.5 ± 21.7) compared to those with multiple rCDI (24.7 ± 21.0; P = 0.039). The mean HrQOL change at follow-up was significantly higher for patients without rCDI (34.1 ± 28.8 increase) compared to patients with rCDI (6.7 ± 19.5 increase; P < 0.001), indicating improvement in anxiety. Conclusions Using the Cdiff32 instrument, we demonstrated that HrQOL worsened significantly in patients with further rCDI. These findings support the use of Cdiff32 in assessing CDI-related humanistic outcomes.
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Affiliation(s)
- Richard L Hengel
- Atlanta ID Group, 275 Collier Rd, Suite 450, Atlanta, GA, 30309, USA.
| | - Claudia P Schroeder
- Healix Infusion Therapy, LLC, 14140 Southwest Freeway, Suite 400, Sugar Land, TX, 77478, USA
| | - Jinhee Jo
- University of Houston College of Pharmacy, 4800 Calhoun Rd, Houston, TX, 77004, USA
| | | | - Ramesh V Nathan
- Los Robles Health System, 215 W Janss Rd, Thousand Oaks, CA, 91360, USA
| | - Anne J Gonzales-Luna
- University of Houston College of Pharmacy, 4800 Calhoun Rd, Houston, TX, 77004, USA
| | - Engels N Obi
- Merck & Co., Inc, 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Ryan J Dillon
- Merck & Co., Inc, 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Lucinda J Van Anglen
- Healix Infusion Therapy, LLC, 14140 Southwest Freeway, Suite 400, Sugar Land, TX, 77478, USA
| | - Kevin W Garey
- University of Houston College of Pharmacy, 4800 Calhoun Rd, Houston, TX, 77004, USA
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Defining the decision problem: A scoping review of economic evaluations for Clostridioides difficile interventions. J Hosp Infect 2021; 121:22-31. [PMID: 34813872 DOI: 10.1016/j.jhin.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is the leading cause of health care-associated infectious diarrhoea. Several preventative and treatment interventions exist, however, decisions for their use are typically made independent of other interventions along the care pathway. AIM To assess how the scope of the decision problem is defined in economic evaluations of C. difficile interventions. METHODS We conducted a scoping review following the Joanna Briggs Institute framework using a comprehensive literature search with C. difficile and economic evaluation as key search concepts. Study selection and extraction was performed independently by two reviewers. We conducted an in-depth analysis of all cost-utility and cost-effectiveness analyses. Care pathway domains (i.e., infection prevention and control, antimicrobial stewardship programs, prevention, diagnostics, treatment) were defined iteratively, and each study was classified according to the scope of the decision problem: a) one intervention, one domain; b) one intervention, multiple domains; c) multiple interventions, one domain; d) multiple interventions, multiple domains. RESULTS A total of 3,886 studies were identified, 116 included in our descriptive overview, and 46 included in our in-depth analysis. Most studies limited the scope of the decision problem to one intervention (43/46; 93%). Only three studies (3/46; 7%) assessed multiple interventions - either as bundled versus standalone interventions for prevention (i.e., a single domain), or as sequences of treatments for initial and recurrent infection (i.e., multiple domains). No study assessed multiple interventions across prevention and treatment domains. CONCLUSIONS Economic evaluations for CDI assess narrowly defined decision problems which may have implications for optimal healthcare resource allocation.
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