Metronidazole therapy as initial treatment of Clostridium difficile infection in patients with chronic kidney disease in Korea.

Jaeuk Shin,Yu Mi Wi,Yu-Ji Lee

doi:10.1017/s0950268819001742

Abstract

The risk of metronidazole treatment failure in Clostridium difficile infection (CDI) patients with chronic kidney disease (CKD) or end-stage renal disease in Korea has not been established. We evaluated 481 patients who had been admitted to two secondary hospitals with a diagnosis of, and treatment for, CDI during 2010-2016. CDI patients were divided into three groups according to CKD status: non-CKD (n = 363), CKD (n = 55) and those requiring dialysis (n = 63). Logistic regression analyses were performed to examine the association of CKD status with treatment failure. CDI patients receiving dialysis tended to have increased odds of metronidazole and overall treatment failure compared to non-CKD patients; adjusted odds ratios and 95% confidence intervals were 2.09 (1.03-4.21) and 2.18 (1.11-4.32) for metronidazole and overall treatment failure, respectively. However, CKD patients did not have increased odds of metronidazole or overall treatment failure compared to non-CKD patients, even where severe CDI was more prevalent in CKD patients. The incidence of symptomatic ileus or toxic megacolon did not differ among groups. Our results suggest that initial metronidazole therapy may be considered in CDI patients with non-dialysis CKD, but should not be considered in CDI patients undergoing dialysis.

Highlights

Clostridium difficile infection (CDI) is the most common cause of transmissible nosocomial diarrhoea and is an increasingly frequent cause of morbidity and mortality among hospitalised patients [1, 2]
A total of 380 patients were initially treated with oral metronidazole: 282 (78%), 42 (76%) and 56 (89%) in non-chronic kidney disease (CKD), CKD and dialysis patients, respectively
CKD and dialysis patients were more likely to receive pump inhibitor (PPI) therapy and concomitant use of antibiotics compared to patients without CKD

Summary

Introduction

Clostridium difficile infection (CDI) is the most common cause of transmissible nosocomial diarrhoea and is an increasingly frequent cause of morbidity and mortality among hospitalised patients [1, 2]. CDI is strongly associated with antibiotic use [4], and other risk factors include older age, gastric acid suppression therapy, immunosuppression, prolonged hospitalisation and chronic kidney disease (CKD) [5,6,7,8]. Gastric acid suppression, increased antibiotic use and altered intestinal microbial flora in CKD patients all contribute to the development of CDI [7, 9, 10]. Outcomes of CDI in patients with CKD or ESRD are known to be worse than in those without CKD, and other contributory factors include increased mortality, longer hospital stays and higher costs associated with CDI [5, 6, 9, 11]

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Conclusion