Cirrhotic Patients With Prior i>Clostridium difficile Infection (CDI) and Recent Hospitalization Are at High-Risk for Recurrent CDI (rCDI) Despite Frequent Use of Rifaximin

Abstract

Introduction: Patients with cirrhosis have an increased risk of CDI and this is associated with increased mortality. However, few studies have examined the rates, outcomes, and predictors of rCDI among patients with cirrhosis. Methods: We retrospectively identified patients admitted to Yale-New Haven Hospital from 2008-2015 with the diagnosis of CDI based on stool toxin assay and presence of diarrhea. From this group, we identified a sub-group of those with cirrhosis defined by either liver biopsy or standard laboratory and imaging findings. Cirrhosis patients with recurrent CDI (Cirr+CDIR) were compared to a control group of cirrhosis patients with only one isolated episode of CDI (Cirr+CDIO). Demographics, medical comorbidities, prior medication exposures, serologic values, and outcomes (30-day, 90-day and 1-year mortality, 30-day readmission) were compared (IBM SPSS 23.0). Results: Of 1,309 patients with CDI, 49 had cirrhosis without history of liver transplant; 18 were Cirr+CDIR and 31 were Cirr+CDIO. The rate of CDI recurrence among cirrhotics was 37% and the majority (61%) had multiple recurrences. There were no significant differences in mortality, readmission, MELD or Charlson co-morbidity scores among Cirr+CDIR and Cirr+CDIO. Cirr+CDIR had higher rates of recent hospitalization (83% vs. 48%, p=0.02) with more frequent use of chronic rifaximin (72% vs. 39%, p=0.04) and lactulose (72% vs.39%, p=0.04) compared with Cirr+CDIO. Metronidazole was the most common antibiotic used to treat initial CDI (78% Cirr+CDIR vs. 71% Cirr+CDIO). Using the significant predictors of recurrence from univariate analysis (varices, recent hospitalization, rifaximin use), multivariate analysis revealed that recent hospitalization within the prior 12-weeks was the only significant predictor of recurrent CDI in patients with cirrhosis (OR 6.0, 95% CI 1.3-28.6, p=0.02). Conclusion: Our study shows that recent hospitalization was the strongest risk factor for recurrence in patients with cirrhosis, despite this cohort receiving chronic rifaximin more frequently than Cirr+CDIO. Inpatients with cirrhosis who develop CDI might benefit from more aggressive therapy to reduce their risk of future recurrence. Further study is needed to clarify the optimal treatment for inpatients with cirrhosis who get CDI to minimize their risk of recurrence.858 Figure 1 No Caption available.