Abstract
Little is known about the incidence and outcomes of Clostridioides difficile infection (CDI) in solid organ transplant (SOT) recipients. To estimate the CDI incidence and outcomes in SOT recipients. A population-based cohort study was conducted using administrative health care data for all Ontario, Canada, residents who received organ allografts from April 1, 2003, to December 31, 2017; March 31, 2020, was the end of the study period. The primary outcome was hospital admission with CDI diagnosis. The secondary outcomes included all-cause death, intensive care unit admission, acute kidney injury requiring dialysis, and fulminant CDI comprising any of the following: toxic megacolon, ileus, perforation, or colectomy. The association between short- vs long-term mortality (ie, death occurring within or after 90 days post-CDI) and the following variables was evaluated: age, sex, Deyo-Charlson Comorbidity Index, SOT type, early- vs late-onset CDI, fulminant CDI, intensive care unit admission, and acute kidney injury requiring acute dialysis. Overall, 10 724 SOT recipients (6901 [64.4%] men; median age, 54 [IQR, 44-62] years) were eligible. Kidney transplant was the most common SOT type (6453 [60.2%]). The median follow-up time was 5.0 (IQR, 2.3-8.8) years, resulting in 61 987 person-years of follow-up. A total of 726 patients (6.8%) were hospitalized with CDI. The 1-year CDI incidence significantly increased in annual cohorts (ie, from 23.1; 95% CI, 12.8-41.8 per 1000 person-years in 2004 to 46.7; 95% CI, 35.0-62.3 per 1000 person-years in 2017; P = .001). Clostridioides difficile was associated with a 16.8% rate (n = 122) of 90-day mortality. In patients who underwent kidney transplant, CDI was typically late-onset (median interval, 2.2; IQR, 0.4-6.0 years) compared with recipients of other organs. Acute kidney injury requiring dialysis was significantly associated with short-term (adjusted odds ratio [aOR], 1.86; 95% CI, 1.07-3.26) and long-term (adjusted hazard ratio [aHR], 1.89; 95% CI, 1.29-2.78) mortality, and late-onset CDI was also significantly associated with a greater risk of short-term (aOR, 4.26; 95% CI, 2.51-7.22) and long-term (aHR, 2.49; 95% CI, 1.78-3.49) mortality. In this study, increasing CDI trends in annual cohorts of SOT recipients were observed. Posttransplant CDI was associated with mortality, and late-onset CDI was associated with a greater risk of death than early-onset CDI. These findings suggest that preventive strategies should not be limited to the initial months following transplantation. Comprehensive therapeutic approaches targeting acute kidney injury risk factors in SOT recipients may reduce short- and long-term post-CDI mortality.
Highlights
Acute kidney injury requiring dialysis was significantly associated with short-term and long-term mortality, and late-onset Clostridioides difficile infection (CDI) was significantly associated with a greater risk of short-term and long-term mortality
Posttransplant CDI was associated with mortality, and late-onset CDI was associated with a greater risk of death than early-onset CDI
CDI frequently occurred within the first year after transplant, recipients of solid organ transplant (SOT) other than the kidney, CDI was typically a late-onset complication in kidney allograft recipients
Summary
Patients who have undergone solid organ transplant (SOT) are at risk of Clostridioides difficile infection (CDI), which is associated with significant morbidity and mortality.[1,2,3] A wide range of the cumulative CDI incidence has been reported in single-center studies[4,5]; SOT-related CDI incidence has been rarely estimated at the population level.[6]Most studies have investigated early-onset CDI occurring within 90 days following transplant.[4,5,6,7] the outcome of late-onset CDI has been rarely investigated.[4,5] early-onset infectious complications may affect allograft function, late-onset infectious diseases may be associated with allograft loss and death.[8,9] To our knowledge, post-CDI mortality has not been compared between patients who underwent SOT developing early- vs late-onset CDI.
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