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Abstract

Introduction: C. difficile represents an important opportunistic infection in transplant patients. In the critical care setting, the severity of illness combined with the lack of data to guide treatment practices poses a particular clinical challenge in this population. We characterize treatment patterns and outcomes for C. difficile infection in transplant patients in the intensive care unit, including initial antibiotic regimen and clinical cure rate. Hypothesis: Due to a lack of specific guidelines for patients with transplantations, varying antibiotics would be used to treat C. difficile infection in critically ill patients with resulting variations in cure rates. Methods: A retrospective chart review was conducted of patients admitted to the intensive care unit between June 2009 and June 2011. Adult patients diagnosed with C. difficile infection and a history of solid organ or bone marrow transplantation were included. Clinical cure was defined as resolution of diarrhea by day six of treatment. Patients were stratified based on infection severity as defined by the IDSA/SHEA clinical guidelines. Outcomes were analyzed using the Chi-squared test. Results: Forty patients were included in the analysis. Metronidazole (n=16), vancomycin (n=18), and a combination of vancomycin and metronidazole (n=6) were initial antibiotic treatments. Clinical cure was seen in 21 (52.5%) patients. Metronidazole was most commonly used in mild to moderate infection (71.4%), vancomycin was most commonly used in severe infection (55.6%), and combination therapy was most common in severe with complications (66.7%). Based on initial treatment regimen, 66.7% of patients on a vancomycin regimen, 50% of patients on metronidazole, and 33.3% on combination therapy achieved a clinical cure, with no significant difference found between groups (p = 0.32). Conclusions: Cure rates observed were lower than those documented in non-critically ill and non-transplant patients. Based on our findings, it would seem reasonable to start all critically ill transplant patients who develop C. difficile infection on vancomycin, but the poor overall cure rates suggest optimal first line therapy still needs to be defined for this challenging population.