Risk Factors for Treatment Failure and Recurrence after Metronidazole Treatment for Clostridium difficile-associated Diarrhea

Epidemiology and Outcomes of Recurrent C Difficile Infection Among Hematopoietic Cell Transplant Recipients: A Single-center, Retrospective 10-year Study

Background

There are limited data on the contemporary epidemiology of recurrent Clostridioides difficile infection (CDI) among hematopoietic cell transplant (HCT) recipients. We aimed to determine the incidence, risk factors, and outcomes for recurrent CDI among HCT recipients.

Methods

We conducted a retrospective study of adult HCT recipients between 2012 and 2021 diagnosed with index CDI between HCT day -7 and +100. Recurrent CDI was defined as new symptoms and a positive test within 12 weeks after treatment for index CDI. Cox proportional hazards models were used to investigate associations between prespecified variables (age, neutropenia, exposure to antibiotics with antianaerobic coverage, cytomegalovirus viremia/disease, and metronidazole monotherapy) and recurrent infection, presented as hazard ratios with 95% confidence intervals (CI).

Results

Of 3479 HCT recipients, 416 (12%) had index CDI and were treated with oral vancomycin (31%), metronidazole (41%), oral vancomycin and metronidazole (29%). Of 381 patients eligible for recurrent CDI analysis, 35 had recurrent infection; cumulative incidence was 10% (95% CI, 7-13) at 12 weeks. In the 14 days after recurrence, 2/25 (8%) patients required hospital admission; none died within 30 days. Metronidazole monotherapy for treatment of index CDI was associated with an increased rate of recurrence (adjusted hazard ratio, 2.0; 95% CI, 1.0-4.0; P = .048).

Conclusions

Recurrent CDI occurred in 10% of HCT recipients in the early posttransplant period and was associated with use of metronidazole. Further study is needed to characterize risk factors for recurrent CDI among HCT recipients to guide use of agents aimed at preventing recurrence.

Epidemiologic characteristics and risk factors of Clostridioides difficile infection in patients with active tuberculosis in the Republic of Korea: a nationwide population-based study

BACKGROUND

The relationship between anti-tuberculosis (TB) agents and Clostridioides difficile infection (CDI) remains unclear. This study aimed to investigate the epidemiological characteristics and risk factors for CDI in patients with TB.

METHODS

This nationwide, population-based cohort study was conducted in the Republic of Korea (ROK) between January 2018 and December 2022. Data were extracted from the National Health Insurance Service-National Health Information Database. The risk factors for CDI in patients with TB were identified through multi-variate logistic regression analysis using a 1:4 greedy matching method based on age and sex.

RESULTS

During the study period, CDI developed in 2901 of the 131,950 patients with TB who were prescribed anti-TB agents. The incidence of CDI in patients with TB has increased annually in the ROK from 12.31/1000 in 2018 to 33.51/1000 in 2022. Oral metronidazole (81.94%) was the most common first-line treatment for CDI. The in-hospital mortality rate of patients with concomitant CDI and TB was 9.9%, compared with 6.9% in those with TB alone (P<0.0001). Multi-variate logistic regression analysis found intensive care unit admission, Charlson Comorbidity Index ≥3, antibiotic exposure, standard regimen, multi-drug-resistant TB and extrapulmonary TB to be significant risk factors for development of CDI in patients with TB.

CONCLUSION

CDI is uncommon in patients with TB, but it results in a significantly increased mortality rate. Patients being treated for TB should be monitored carefully for the development of CDI. Further clinical research is warranted to identify effective interventions for preventing and controlling CDI during TB treatment.

Impact of diabetic ketoacidosis on outcomes in hospitalized diabetic patients with Clostridioides difficile infection: a national inpatient analysis

Introduction

Diabetic ketoacidosis (DKA) is a critical diabetic emergency with life-threatening complications. The impact of DKA on hospital outcomes in diabetic patients with Clostridioides difficile infection (CDI) remains unclear.

Methods

This retrospective analysis used data from the 2016 to 2020 National Inpatient Survey. Adults with diabetes and CDI were categorized into groups with and without DKA. Hospitalization characteristics, comorbidities, and clinical outcomes were compared. Primary outcomes included mortality, length of stay, and total hospital charges. Secondary outcomes included CDI complications. Multivariate logistic regression analysis was conducted, with P values ≤ 0.05 considered statistically significant.

Results

Among 494,664 diabetic patients with CDI, 6130 had DKA. Patients with DKA had significantly higher total hospital charges ($194,824 vs $103,740, P < 0.001) and longer length of stay (10.14 vs 6.04 days, P < 0.001). After adjusting for confounders, DKA patients had increased odds of mortality (adjusted odds ratio [aOR] 2.07), sepsis (aOR 1.40), septic shock (aOR 1.76), cardiac arrest (aOR 3.24), vasopressor use (aOR 2.01), and mechanical ventilation (aOR 1.96) (all P < 0.001).

Conclusion

The presence of DKA significantly elevates hospital burden and CDI complications in diabetic patients. These findings underscore the need for close monitoring and aggressive management of DKA in patients with concurrent CDI to improve outcomes.

Clostridium butyricum therapy for mild-moderate Clostridioides difficile infection and the impact of diabetes mellitus

The therapeutic effect of Clostridium butyricum for adults with Clostridioides difficile infection (CDI) was investigated. A retrospective study was conducted in medical wards of Tainan Hospital, Ministry of Health and Welfare, between January 2013 and April 2020. The disease severity of CDI was scored based on the Clinical Practice Guidelines of the IDSA/SHEA. Treatment success was defined as the resolution of diarrhea within six days of a therapeutic intervention without the need to modify the therapeutic regimen. In total, 241 patients developed CDI during hospitalization in the study period. The treatment success rates for the 99 patients with mild-moderate CDI among them were as follows: metronidazole, 69.4%; C. butyricum, 68.2%; metronidazole plus C. butyricum, 66.7%; and oral vancomycin, 66.7% (p=1.00). Patients with treatment success were less likely to have diabetes mellitus than those with treatment failure (38.2% vs. 61.3%, p=0.05). Patients treated with C. butyricum alone or in combination with metronidazole had shorter durations of diarrhea than those treated with metronidazole alone (3.1 ± 2.0 days or 3.5 ± 2.4 days vs. 4.2 ± 3.5 days; p=0.43 or 0.71), although the differences were not statistically significant. In conclusion, the treatment success rate of C. butyricum alone or in combination with metronidazole for patients with CDI was non inferior to that of metronidazole alone. The presence of diabetes mellitus in affected individuals is a risk factor for treatment failure.

In vivo efficacy of auranofin in a hamster model of Clostridioides difficile infection

Clostridioides difficile infections (CDIs) are an urgent public health threat worldwide and are a leading cause of morbidity and mortality in healthcare settings. The increasing incidence and severity of infections combined with the scarcity of effective anti-CDI agents has made treatment of CDI very challenging. Therefore, development of new, effective anticlostridial agents remains a high priority. The current study investigated the in vivo efficacy of auranofin in a CDI hamster model. All hamsters treated with auranofin (5 mg/kg) survived a lethal challenge with C. difficile. Furthermore, auranofin (5 mg/kg) was as effective as vancomycin, the drug of choice for treatment of CDIs, against relapsing CDI. Furthermore, auranofin (5 mg/kg) generated a 3.15-log₁₀ reduction (99.97%) in C. difficile count in the cecal contents of hamsters. These results indicate that auranofin warrants further investigation as a new agent to replenish the pipeline of anti-CDI therapeutics.

Auranofin, at clinically achievable dose, protects mice and prevents recurrence from Clostridioides difficile infection

Clostridioides difficile is the leading cause of nosocomial infections and a worldwide urgent public health threat. Without doubt, there is an urgent need for new effective anticlostridial agents due to the increasing incidence and severity of C. difficile infection (CDI). The aim of the present study is to investigate the in vivo efficacy of auranofin (rheumatoid arthritis FDA-approved drug) in a CDI mouse model and establish an adequate dosage for treatment. The effects of increased C. difficile inoculum, and pre-exposure to simulated gastric intestinal fluid (SGF) and simulated intestinal fluid (SIF), on the antibacterial activity of auranofin were investigated. Auranofin's in vitro antibacterial activity was stable in the presence of high bacterial inoculum size compared to vancomycin and fidaxomicin. Moreover, it maintained its anti-C. difficile activity after being exposed to SGF and SIF. Upon testing in a CDI mouse model, auranofin at low clinically achievable doses (0.125 mg/kg and 0.25 mg/kg) significantly protected mice against CDI with 100% and 80% survival, respectively. Most importantly, auranofin (0.125 mg/kg and 0.25 mg/kg) significantly prevented CDI recurrence when compared with vancomycin. Collectively, these results indicate that auranofin could potentially provide an effective, safe and quick supplement to the current approaches for treating CDI.

Risk factors for recurrent Clostridium difficile infection in a tertiary hospital in Israel

To estimate the rate and identified risk factors for recurrent Clostridium difficile infection (rCDI) in Israel. We conducted a retro-prospective case-control study of all adult (age ≥ 18 years) patients with an initial episode of CDI (iCDI) at Tel Aviv Sourasky Medical Center from January 1, 2012 to December 31, 2014. We collected demographic, clinical, and epidemiological information for patients who were classified as recurrent (cases) and non-recurrent (control) groups. In total, 648 patients with iCDI were identified in the study. During the 36-month study period, 82 (12.7%) patients had at least one rCDI identified. We identified several factors as independent variables significantly associated with recurrent CDI: functional disability, severity of the initial infection, continuous non-Clostridium difficile antibiotic treatment with third-generation cephalosporins or clindamycin, and iCDI treatment with metronidazole and vancomycin; however, neutropenia had high measure of effect as a predictor for rCDI (adjusted odds ratio, 7.9; 95% confidence interval, 1.27-49.58; p = 0.026). The identification of the main modifiable risk factors for recurrent CDI, continuous non-Clostridium difficile antibiotics after diagnosis of the initial infection, and antibiotic treatment with third-generation cephalosporins or clindamycin are critical in reducing the spread of recurrent infection with Clostridium difficile in hospital.

Epidemiology and risk factors for Clostridium difficile-associated diarrhea in adult inpatients in a university hospital in China

BACKGROUND

Clostridium difficile-associated diarrhea (CDAD) is an important disease with rising incidence and mortality in western countries. However, studies about CDAD in China are limited. The aims of this study are to investigate the epidemiology and risk factors of CDAD in a university hospital located in Eastern China.

METHODS

Diarrhea samples of all adult inpatients were collected for C difficile culture prospectively from August 2013-April 2014. Suspected colonies were identified by biochemical identification cards. Confirmed C difficile isolates were further analyzed for the presence of toxin genes and typed by polymerase chain reaction ribotyping. Patient demographics, presumed risk factors, clinical manifestations, and laboratory findings were collected through inpatient medical record systems retrospectively.

RESULTS

In total, 45 stains of toxigenic C difficile were isolated from 315 nonrepetitive diarrhea samples. The isolation rate was 14.29% (45/315). No RT027/ST1 strain was found. An outbreak of CDAD occurred in the digestive ward and was finally found to be caused by ST35 strains during this study. Coloclysis and diabetes were found to be independent risk factors of CDAD, besides the common risk factors previously reported.

CONCLUSIONS

CDAD is not uncommon in Chinese hospitals. C difficile ST35 as a new strain causing outbreaks should be noticed. Coloclysis and diabetes are new independent risk factors for CDAD, and further study is needed.

Recognition and management of Clostridium difficile in older adults

Clostridium difficile infection (CDI) is increasing in the outpatient setting, and older adults are at a higher risk for contracting CDI and experiencing poor outcomes. NPs may see this infection in the primary care setting. This article focuses on the presentation, treatment, and clinical practice implications for CDI in community-dwelling older adults.

Toxigenic Clostridium difficile in retail packed chicken meat and broiler flocks in northeastern Iran

This study was designed to evaluate the occurrence of Clostridium difficile in both broiler chicken farms and packed chicken parts sold at market places in Mashhad, the second most popular Islamic pilgrimage city after Mecca in northeastern Iran. The fresh faecal samples were obtained from broiler farms, while the chicken packs were purchased from retail outlets across the city at market places and samples were obtained from the necks, thighs, and wings. The selective culture was used for isolation of C. difficile. Out of 40 pooled fresh faecal and 65 packed chicken samples, 14 (35%) and 10 (15.3%) samples were positive, respectively. Some of the C. difficile isolates from chickens packs (7 out of 10, 70%) and faecal samples (5 out of 14, 36%) were detected as toxigenic (A, B and binary toxins) using molecular identification. From 14 isolates of the faecal samples, five isolates were tcdA and tcdB positive, and none was binary toxin positive. The results of the present study suggest that broiler chickens are a potential source of C. difficile, which may infect humans through contact or consumption of chicken meat, although the significance of food contamination is entirely unclear, the role of poultry products as a potential source of the infection should be investigated.

Body mass index greater than 35 is associated with severe Clostridium difficile infection

BACKGROUND

Obesity has been implicated in the acquisition of Clostridium difficile infections (CDI), however, no study has investigated whether there is a correlation between body mass index (BMI) and CDI severity.

AIM

To determine whether obesity, as measured by BMI correlates with severe hospital-onset or community-onset CDI.

METHODS

Patients admitted with CDI at a tertiary-care center from January 2013 to June 2015 were identified. The cohort was stratified by onset of disease using the National Healthcare Safety Network criteria, and by severity using the 2013 American College of Gastroenterology guidelines. Multivariate logistic regression was used to determine independent predictors of severe CDI.

RESULTS

A total of 196 met the inclusion criteria, of which 57.1% (112) met criteria for severe disease. Overall, BMI >35 kg/m² was 1.7-fold more likely to be associated with severe CDI compared to a BMI 20-35 kg/m² (P < 0.005), and was an independent predictor of severe CDI (P = 0.038). In patients with community-onset-CDI and hospital-onset-CDI, a BMI >35 kg/m² was associated with a 1.96-fold and 1.48 greater rate of severe CDI compared to a BMI 20-35 kg/m² (P = 0.004 and 0.048), and was an independent predictor of severe CDI in these cohorts (P = 0.039 and 0.027) respectively.

CONCLUSION

This study has identified an association between body mass index and Clostridium difficile infection severity. A BMI>35 kg/m² is an independent risk factor for severe community-onset and hospital-onset Clostridium difficile infections.

Clostridium difficile infection in patients hospitalized with type 2 diabetes mellitus and its impact on morbidity, mortality, and the costs of inpatient care

AIMS

Type 2 diabetes mellitus (T2DM) is often complicated by infections leading to hospitalization, increased morbidity, and mortality. Not much is known about the impact of Clostridium difficile infection (CDI) on health outcomes in hospitalized patients with T2DM. We estimated the prevalence and temporal trends of CDI; evaluated the associations between CDI and in-hospital mortality, length of stay (LOS), and the costs of inpatient care; and compared the impact of CDI with that of other infections commonly seen in patients with T2DM.

METHODS

We conducted a cross-sectional analysis using data from the Nationwide Inpatient Sample among patients ⩾18years with T2DM and generalized linear regression was used to analyze associations and jointpoint regression for trends.

RESULTS

The prevalence of CDI was 6.8 per 1000 hospital discharges. Patients with T2DM and CDI had increased odds of in-hospital mortality (OR, 3.63; 95% CI 3.16, 4.17). The adjusted mean LOS was higher in patients with CDI than without CDI (11.9 vs. 4.7days). That translated to average hospital costs of $23,000 and $9100 for patients with and without CDI, respectively. The adjusted risk of mortality in patients who had CDI alone (OR 3.75; 95% CI 3.18, 4.41) was similar to patients who had CDI in addition to other common infections (OR 3.25; 95% CI 2.58, 4.10).

CONCLUSION

CDI is independently associated with poorer health outcomes in patients with T2DM. We recommend close surveillance for CDI in hospitalized patients and further studies to determine the cost effectiveness of screening for CDI among patients with T2DM.

Factors Predicting Recurrence of Clostridium difficile Infection (CDI) in Hospitalized Patients: Retrospective Study of More Than 2000 Patients

BACKGROUND

Clostridium difficile infection (CDI) has increased in incidence and severity worldwide, causing direct costs estimated to range from US $3.2 billion to $4.8 billion. The aim of this study was to investigate and identify factors that predict recurrence of CDI.

METHODS

This was a retrospective case-control study between 2007 and 2013 on patients admitted with CDI. Recurrent CDI is defined as a new episode of diarrhea within 90 days confirmed by a positive stool C. difficile toxin assay or polymerase chain reaction, after resolution of the initial CDI episode for at least 10 days and after discontinuation of the CDI therapy.

RESULTS

Three thousand twenty patients were diagnosed with CDI between January 2007 and December 2013. Two hundred nine of 2019 patients in the study had a recurrence of CDI within 90 days of the end of the initial CDI episode (10.3%). Multivariate analysis showed that most of the recurrences occurred in patients with comorbidities, particularly chronic kidney disease (odds ratio, 1.3; 95% confidence interval [CI], 1.0-2.4; P = 0.039). In addition, a higher percentage of patients in the recurrence group were prescribed proton-pump inhibitors (odds ratio, 1.65; 95% CI, 1.0-1.7; P = 0.002) and steroids (odds ratio, 1.65; 95% CI, 1.0-1.5; P = 0.047).

CONCLUSIONS

Our data suggest that the use of glucocorticoids, use of proton-pump inhibitors, and having end-stage renal disease are significant risk factors associated with recurrent CDI.

Subinhibitory concentrations of metronidazole increase biofilm formation in Clostridium difficile strains

Resistance mechanism to metronidazole is still poorly understood, even if the number of reports on Clostridium difficile strains with reduced susceptibility to this antibiotic is increasing. In this study, we investigated the ability of the C. difficile strains 7032994, 7032985 and 7032989, showing different susceptibility profiles to metronidazole but all belonging to the PCR ribotype 010, to form biofilm in vitro in presence and absence of subinhibitory concentrations of metronidazole. The quantitative biofilm production assay performed in presence of metronidazole revealed a significant increase in biofilm formation in both the susceptible strain 7032994 and the strain 7032985 exhibiting a reduced susceptibility to this antibiotic, while antibiotic pressure did not affect the biofilm-forming ability of the stable-resistant strain 7032989. Moreover, confocal microscopy analysis showed an abundant biofilm matrix production by the strains 7032994 and 7032885, when grown in presence of metronidazole, but not in the stable-resistant one. These results seem to demonstrate that subinhibitory concentrations of metronidazole are able to enhance the in vitro biofilm production of the above-mentioned PCR ribotype 010 C. difficile strains, susceptible or with reduced susceptibility to this antibiotic, suggesting a possible role of biofilm formation in the multifactorial mechanism of metronidazole resistance developed by C. difficile.

Adherence to and Outcomes Associated with a Clostridium difficile Guideline at a Large Teaching Institution

PURPOSE

The incidence and virulence of Clostridium difficile infection (CDI) has recently increased. National CDI treatment guidelines stratify patients based on clinical symptoms and recommend treatment based on severity of illness. In 2009, Advocate Lutheran General Hospital (Park Ridge, Illinois) adopted guidelines with treatment algorithms identical to the national guidelines. The purpose of this study was to determine whether patients were being treated in accordance with the CDI guidelines and whether adherence impacted patient outcomes.

METHODS

This was a retrospective, descriptive study. Subjects were identified by CDI-associated ICD-9 codes from July 1, 2009 to June 30, 2011 and stratified by disease severity. Guideline adherence was assessed based on initial treatment selection, and subjects were then further categorized as undertreated (UT), overtreated (OT), or appropriately treated (AT). Secondary endpoints included need for therapy escalation, clinical cure, recurrence rates, 90-day all-cause mortality, proton pump inhibitor (PPI), and antimicrobial use.

RESULTS

Two hundred fifty subjects totaling 324 encounters were analyzed. Overall guideline adherence was 42.9%. Adherence rates by CDI severity were mild-moderate, 53.9%; severe, 39.0%; and severe-complicated, 17.9% (P < .001). Of all the subjects, 42.9% were AT, 30.9% were OT, and 26.2% were UT. Clinical outcomes between UT versus AT subjects were as follows: therapy escalation required, 34.1% versus 27.5% (P = .289); clinical cure, 41.2% versus 55.7% (P = .033); mortality, 24.7% versus 10.1% (P = .003); and recurrence, 44.7% versus 24.8% (P < .02). Clinical outcomes between AT versus OT subjects were as follows: therapy escalation required 27.5% versus 14.4% (P < .02); clinical cure, 55.7% versus 66.7% (P = .089); mortality, 10.1% versus 7.8% (P = .553); recurrence, 24.8% versus 27.8% (P = .871).

CONCLUSIONS

The majority of subjects were not treated according to CDI guidelines, particularly those with severe and severe-complicated disease. UT subjects had worse clinical outcomes and OT subjects failed to show significant improvements in clinical outcomes compared to AT subjects. Emphasis should be placed on CDI guideline adherence as this may be associated with improved outcomes.

Risk factors for recurrent Clostridium difficile infection: a systematic review and meta-analysis

OBJECTIVE

An estimated 20-30% of patients with primary Clostridium difficile infection (CDI) develop recurrent CDI (rCDI) within 2 weeks of completion of therapy. While the actual mechanism of recurrence remains unknown, a variety of risk factors have been suggested and studied. The aim of this systematic review and meta-analysis was to evaluate current evidence on the risk factors for rCDI.

DESIGN

We searched MEDLINE and 5 other databases for subject headings and text related to rCDI. All studies investigating risk factors of rCDI in a multivariate model were eligible. Information on study design, patient population, and assessed risk factors were collected. Data were combined using a random-effects model and pooled relative risk ratios (RRs) were calculated.

RESULTS

A total of 33 studies (n=18,530) met the inclusion criteria. The most frequent independent risk factors associated with rCDI were age≥65 years (risk ratio [RR], 1.63; 95% confidence interval [CI], 1.24-2.14; P=.0005), additional antibiotics during follow-up (RR, 1.76; 95% CI, 1.52-2.05; P<.00001), use of proton-pump inhibitors (PPIs) (RR, 1.58; 95% CI, 1.13-2.21; P=.008), and renal insufficiency (RR, 1.59; 95% CI, 1.14-2.23; P=.007). The risk was also greater in patients previously on fluoroquinolones (RR, 1.42; 95% CI, 1.28-1.57; P<.00001).

CONCLUSIONS

Multiple risk factors are associated with the development of rCDI. Identification of modifiable risk factors and judicious use of antibiotics and PPI can play an important role in the prevention of rCDI.

Adherence to and Outcomes Associated with a Clostridium difficile Guideline at a Large Teaching Institution

Purpose

The incidence and virulence of Clostridium difficile infection (CDI) has recently increased. National CDI treatment guidelines stratify patients based on clinical symptoms and recommend treatment based on severity of illness. In 2009, Advocate Lutheran General Hospital (Park Ridge, Illinois) adopted guidelines with treatment algorithms identical to the national guidelines. The purpose of this study was to determine whether patients were being treated in accordance with the CDI guidelines and whether adherence impacted patient outcomes.

Methods

This was a retrospective, descriptive study. Subjects were identified by CDI-associated ICD-9 codes from July 1, 2009 to June 30, 2011 and stratified by disease severity. Guideline adherence was assessed based on initial treatment selection, and subjects were then further categorized as undertreated (UT), overtreated (OT), or appropriately treated (AT). Secondary endpoints included need for therapy escalation, clinical cure, recurrence rates, 90-day all-cause mortality, proton pump inhibitor (PPI), and antimicrobial use.

Results

Two hundred fifty subjects totaling 324 encounters were analyzed. Overall guideline adherence was 42.9%. Adherence rates by CDI severity were mild-moderate, 53.9%; severe, 39.0%; and severe-complicated, 17.9% ( P < .001). Of all the subjects, 42.9% were AT, 30.9% were OT, and 26.2% were UT. Clinical outcomes between UT versus AT subjects were as follows: therapy escalation required, 34.1% versus 27.5% ( P = .289); clinical cure, 41.2% versus 55.7% ( P = .033); mortality, 24.7% versus 10.1% ( P = .003); and recurrence, 44.7% versus 24.8% ( P < .02). Clinical outcomes between AT versus OT subjects were as follows: therapy escalation required 27.5% versus 14.4% ( P < .02); clinical cure, 55.7% versus 66.7% ( P = .089); mortality, 10.1% versus 7.8% ( P = .553); recurrence, 24.8% versus 27.8% ( P = .871).

Conclusions

The majority of subjects were not treated according to CDI guidelines, particularly those with severe and severe-complicated disease. UT subjects had worse clinical outcomes and OT subjects failed to show significant improvements in clinical outcomes compared to AT subjects. Emphasis should be placed on CDI guideline adherence as this may be associated with improved outcomes.

Long-Term Clinical Outcome of Clostridium difficile Infection in Hospitalized Patients: A Single Center Study

Background/Aims

Antibiotic usage and increasingly aging populations have led to increased incidence of Clostridium difficile infection (CDI) in worldwide. Recent studies in Korea have also reported increasing CDI incidence; however, there have been no reports on the long-term outcomes of CDI. We therefore investigated the long-term clinical outcomes of patients with CDI, including delayed recurrence, associated risk factors and mortality.

Methods

Hospitalized patients diagnosed with CDI at Seoul Paik Hospital between January 2007 and December 2008 were included. Their medical records were retrospectively investigated. 'Delayed recurrence' was defined as a relapse 8 weeks after a successful initial treatment. Multivariate logistic regression analysis was performed to identify risk factors for the delayed recurrence. Kaplan-Meier curves were used to analyze mortality rates.

Results

A total of 120 patients were enrolled; among them, 87 were followed-up for at least 1 year, with a mean follow-up period of 34.1±25.1 months. Delayed recurrence was observed in 17 patients (19.5%), and significant risk factors were age (over 70 years, P=0.049), nasogastric tube insertion (P=0.008), and proton pump inhibitor or H₂-blocker treatments (P=0.028). The 12- and 24-month mortality rates were 24.6% and 32.5%, respectively. No deaths were directly attributed to CDI.

Conclusions

Delayed recurrence of CDI was not rare, occurring in 19.5% of the study population. Although CDI-related mortality was not reported, 2-year (32.5%) mortality rate of CDI patients implies that a CDI diagnosis may predict severe morbidity and poor prognosis of the underlying disease.

Clostridium difficile infection in diabetes

Diabetes-related hospitalization and hospital utilization is a serious challenge to the health care system, a situation which may be further aggravated by nosocomial Clostridium difficile (C. difficile) infection (CDI). Studies have demonstrated that diabetes increases the risk of recurrent CDI with OR (95% CI) 2.99 (1.88, 4.76). C. difficile is a gram-positive, spore-forming anaerobic bacterium which is widely distributed in the environment. Up to 7% of healthy adults and up to 45% of infants may have asymptomatic intestinal carriage of C. difficile. A large number of strains of C. difficile have been identified. A number of PCR or sequence-based molecular typing methods are available for typing C. difficile isolates. C. difficile virulence evolved independently in the highly epidemic lineages, associated with the expression of toxin genes and other virulence factors. This article briefly reviews recent progresses in the bateriology of C. difficile and highlights the limited knowledge of potential mechanisms for the increased risk of CDI in diabetes which warrants further research.

Risk factors for recurrence, complications and mortality in Clostridium difficile infection: a systematic review

BACKGROUND

Clostridium difficile infection (CDI) can lead to complications, recurrence, and death. Numerous studies have assessed risk factors for these unfavourable outcomes, but systematic reviews or meta-analyses published so far were limited in scope or in quality.

METHODS

A systematic review was completed according to PRISMA guidelines. An electronic search in five databases was performed. Studies published until October 2013 were included if risk factors for at least one CDI outcome were assessed with multivariate analyses.

RESULTS

68 studies were included: 24 assessed risk factors for recurrence, 18 for complicated CDI, 8 for treatment failure, and 30 for mortality. Most studies accounted for mortality in the definition of complicated CDI. Important variables were inconsistently reported, such as previous episodes and use of antibiotics. Substantial heterogeneity and methodological limitations were noted, mainly in the sample size, the definition of the outcomes and periods of follow-up, precluding a meta-analysis. Older age, use of antibiotics after diagnosis, use of proton pump inhibitors, and strain type were the most frequent risk factors for recurrence. Older age, leucocytosis, renal failure and co-morbidities were frequent risk factors for complicated CDI. When considered alone, mortality was associated with age, co-morbidities, hypo-albuminemia, leucocytosis, acute renal failure, and infection with ribotype 027.

CONCLUSION

Laboratory parameters currently used in European and American guidelines to define patients at risk of a complicated CDI are adequate. Strategies for the management of CDI should be tailored according to the age of the patient, biological markers of severity, and underlying co-morbidities.

Risk factors for recurrence, complications and mortality in Clostridium difficile infection: a systematic review

BACKGROUND

Clostridium difficile infection (CDI) can lead to complications, recurrence, and death. Numerous studies have assessed risk factors for these unfavourable outcomes, but systematic reviews or meta-analyses published so far were limited in scope or in quality.

METHODS

A systematic review was completed according to PRISMA guidelines. An electronic search in five databases was performed. Studies published until October 2013 were included if risk factors for at least one CDI outcome were assessed with multivariate analyses.

RESULTS

68 studies were included: 24 assessed risk factors for recurrence, 18 for complicated CDI, 8 for treatment failure, and 30 for mortality. Most studies accounted for mortality in the definition of complicated CDI. Important variables were inconsistently reported, such as previous episodes and use of antibiotics. Substantial heterogeneity and methodological limitations were noted, mainly in the sample size, the definition of the outcomes and periods of follow-up, precluding a meta-analysis. Older age, use of antibiotics after diagnosis, use of proton pump inhibitors, and strain type were the most frequent risk factors for recurrence. Older age, leucocytosis, renal failure and co-morbidities were frequent risk factors for complicated CDI. When considered alone, mortality was associated with age, co-morbidities, hypo-albuminemia, leucocytosis, acute renal failure, and infection with ribotype 027.

CONCLUSION

Laboratory parameters currently used in European and American guidelines to define patients at risk of a complicated CDI are adequate. Strategies for the management of CDI should be tailored according to the age of the patient, biological markers of severity, and underlying co-morbidities.

The association between histamine 2 receptor antagonist use and Clostridium difficile infection: a systematic review and meta-analysis

BACKGROUND

Clostridium difficile infection (CDI) is a major health problem. Epidemiological evidence suggests that there is an association between acid suppression therapy and development of CDI.

PURPOSE

We sought to systematically review the literature that examined the association between histamine 2 receptor antagonists (H2RAs) and CDI.

DATA SOURCE

We searched Medline, Current Contents, Embase, ISI Web of Science and Elsevier Scopus from 1990 to 2012 for all analytical studies that examined the association between H2RAs and CDI.

STUDY SELECTION

Two authors independently reviewed the studies for eligibility.

DATA EXTRACTION

Data about studies characteristics, adjusted effect estimates and quality were extracted.

DATA SYNTHESIS

Thirty-five observations from 33 eligible studies that included 201834 participants were analyzed. Studies were performed in 6 countries and nine of them were multicenter. Most studies did not specify the type or duration of H2RAs therapy. The pooled effect estimate was 1.44, 95% CI (1.22-1.7), I(2) = 70.5%. This association was consistent across different subgroups (by study design and country) and there was no evidence of publication bias. The pooled effect estimate for high quality studies was 1.39 (1.15-1.68), I2 = 72.3%. Meta-regression analysis of 10 study-level variables did not identify sources of heterogeneity. In a speculative analysis, the number needed to harm (NNH) with H2RAs at 14 days after hospital admission in patients receiving antibiotics or not was 58, 95% CI (37, 115) and 425, 95% CI (267, 848), respectively. For the general population, the NNH at 1 year was 4549, 95% CI (2860, 9097).

CONCLUSION

In this rigorous systematic review and meta-analysis, we observed an association between H2RAs and CDI. The absolute risk of CDI associated with H2RAs is highest in hospitalized patients receiving antibiotics.

Consequences of Clostridium difficile infection: understanding the healthcare burden

Clostridium difficile is the leading cause of infectious nosocomial diarrhoea in developed countries, with a measured incidence of approximately five episodes per 10,000 days of hospital stay in Europe. Accurate diagnosis of C. difficile infection (CDI) is a prerequisite for obtaining reliable epidemiological data, but in many European countries diagnosis is probably suboptimal. A significant percentage of CDI cases are missed because clinicians often fail to request tests for C. difficile toxins in cases of unexplained diarrhoea. In addition, some laboratories continue to use tests of low sensitivity or apply them inappropriately. In one study in Spain, failure to request CDI testing in more than two-thirds of patients with unexplained diarrhoea led to significant underdiagnosis of cases. A recent pan-European survey revealed huge discrepancies in the rate of CDI testing across Europe, which suggests that epidemiological reports underestimate the true incidence of CDI in many parts of Europe. This is important because, as this review of the clinical and economic burden of CDI illustrates, infection with C. difficile imposes a significant burden not only on patients, owing to increased morbidity and mortality, but also on healthcare systems and society in general. On the basis of current incidence rates, annual costs for management of CDI amount to approximately $800 million in the USA and €3000 million in Europe. Moreover, estimates suggest that costs associated with recurrent CDI can exceed those of primary CDI. Measures to more effectively prevent CDI and reduce CDI recurrence rates may help to reduce this burden.

Recent changes in Clostridium difficile infection

Clostridium difficile is the main cause of nosocomial diarrhea. Diarrhea associated with C. difficile has increased incidence, morbidity, and mortality in the last few years. The major related risk factors include use of antibiotics, elderly patients and prolonged hospital stay. Many patients receive combinations of antibiotics or multiple antibiotics, which represents the main risk to develop diarrhea associated to C. difficile or its recurrence. Therefore, interventions to improve antibiotic prescribing, as well as compliance with infection control measures can reduce hospital-acquired C. difficile infections. This review addresses the epidemiological changes in C. difficile disease and its treatment.

Treatment failure and recurrence of Clostridium difficile infection following treatment with vancomycin or metronidazole: a systematic review of the evidence

The objective of this review was to evaluate the frequency of treatment failure and recurrence of Clostridium difficile infection (CDI) following treatment with vancomycin or metronidazole in recently performed studies (last 10 years). Searches in PubMed and Scopus were performed by two reviewers independently. Data regarding treatment failure and recurrence following metronidazole and vancomycin treatment were extracted and analysed. In total, 39 articles (7005 patients) were selected for inclusion in the systematic review. The reported treatment failure was 22.4% with metronidazole (16 studies) and 14.2% with vancomycin (8 studies). Recurrence of CDI occurred in 27.1% of patients following metronidazole treatment (18 studies) and 24.0% of patients following vancomycin treatment (8 studies). Mean treatment failure and recurrence in the selected studies was 22.3% (24 studies) and 22.1% (37 studies). The reported outcomes depended on the study design (higher in prospective and retrospective cohort studies than in randomised controlled trials), geographic location of the study (higher in North America than in Europe and Asia), funding (higher in studies funded by non-profit organisations than pharmaceutical companies), mean age of the studied population (higher in older patients) and duration of follow-up (higher in studies with follow-up >1 month). In conclusion, infection with C. difficile is associated with 22.4% and 14.2% treatment failure and 27.1% and 24.0% recurrence after treatment with metronidazole and vancomycin, respectively. The variation in the reported outcomes amongst studies depends on the study design, location, funding, age and follow-up period.

Epidemiology and clinical characteristics of Clostridium difficile infection in a Korean tertiary hospital

In order to investigate the incidence, clinical and microbiologic characteristics of Clostridium difficile infection (CDI) in Korea, a prospective observational study was performed. From September 2008 through January 2010, all patients whose stool was tested for toxin assay A&B and/or C. difficile culture were studied for clinical characteristics. Toxin types of the isolates from stool were tested. The mean incidence of CDI per 100,000 patient-days was 71.6 by month (range, 52.5-114.0), and the ratio of CDI to antibiotic-associated diarrhea was 0.23. Among 200 CDI patients, 37.5% (75/200) was severe CDI based on severity score. Clinical outcome of 189 CDI was as followed; 25.9% (49/189) improved without treatment, 84.3% (118/140) achieved clinical cure and attributed mortality was 0.7% (1/140) with the treatment. Recurrence rate was 21.4% (30/140) and cure without recurrence was 66.4% (93/140). The most common type of toxin was toxin A-positive/toxin B-positive strain (77.5%), toxin A-negative/toxin B-positive strains or binary toxin-producing strains comprised 15.4% or 7.1%, respectively. In conclusion, the incidence of CDI in Korea is a little higher than other reports during the non-epidemic setting. We expect that the change of epidemiology and clinical severity in CDI can be evaluated based on these results.

Risk factors for recurrence of Clostridium difficile infection: effect of vancomycin-resistant enterococci colonization

Recurrent Clostridium difficile infection (CDI) is one of the most difficult problems in healthcare infection control. We evaluated the risk factors associated with recurrence in patients with CDI. A retrospective cohort study of 84 patients with CDI from December 2008 through October 2010 was performed at Pusan National University Yangsan Hospital. Recurrence occurred in 13.1% (11/84) of the cases and in-hospital mortality rate was 7.1% (6/84). Stool colonization with vancomycin-resistant enterococci (VRE) (P = 0.006), exposure to more than 3 antibiotics (P = 0.009), low hemoglobin levels (P = 0.025) and continued use of previous antibiotics (P = 0.05) were found to be more frequent in the recurrent group. Multivariate analysis indicated that, stool VRE colonization was independently associated with CDI recurrence (odds ratio, 14.519; 95% confidence interval, 1.157-182.229; P = 0.038). This result suggests that stool VRE colonization is a significant risk factor for CDI recurrence.