Risk Factors For Clostridioides Difficile Infection Research Articles

Risk of Hospital-Onset C. difficile Infection Increases With Prior Inpatient and Outpatient Visits

Background:Clostridioides difficile is a leading cause of healthcare-associated infections, and greater healthcare exposure is a primary risk factor for Clostridioides difficile infection (CDI). Longer hospital stays and greater CDI pressure, both at the hospital level and the level, have been linked to greater risk. In addition, symptoms associated with healthcare-associated CDI often do not present until a patient has been discharged. Our study objective was to estimate the extent to which exposure to different types of healthcare settings (eg, prior hospitalization, emergency department [ED], outpatient or long-term care) increase risk for hospital-onset CDI. Methods: We conducted a case-control study using the Truven Marketscan Commerical Claims and Medicare Supplemental databases from 2001 to 2017. Case patients were selected as all inpatient visits with a secondary diagnosis of CDI and no previous CDI diagnosis in the prior 90 days. Controls were selected from all inpatient admissions without any CDI diagnosis during the current admission or prior 90 days. A logistic regression model was used to estimate risk associated with prior healthcare exposure. Indicators were created for prior exposure to different healthcare settings: separate indicators were used to indicate transfer, exposure to that setting in the prior 1–30 days, 31–60 days and 61–90 days. Separate indicators were created for prior hospitalization, ED, outpatient clinic, nursing home or long-term care facilities (LTCFs), psychiatric or substance-abuse facility or other outpatient facility. We also included an indicator for prior exposure to a family member with CDI and prior outpatient antibiotics. Results: Estimates for selected variables (odds ratios) are presented in Table 1. Prior hospitalization, ED visits, outpatient clinics, nursing home and LTCFs were all associated with increased risk of secondary diagnosed CDI. Prior hospitalization and nursing home/LTCF conveyed the greatest risk. In addition, a ‘dose-–response’ relationship occurred for each of these exposure settings, with exposure nearest the admission date having the largest risk. Prior exposure to psychiatric , substance abuse, or other outpatient facilities were not risk factors for CDI. Having a family member with prior CDI and both low-risk and high-risk outpatient antibiotics were associated with increased risk. These factors also exhibited a ‘dose–response’ pattern. Conclusions: Exposure to various healthcare settings significantly increased risk for secondary CDI. Prior healthcare exposures occurring nearest to the point of admission conveyed the greatest risk. These results suggest that many hospital-associated CDI cases attributed to a current hospital stay may actually be acquired from prior healthcare settings.Funding: CDC Modeling Infectious Diseases (MInD) in Healthcare NetworkDisclosures: None

Temporal Change of Risk Factors in Hospital-Acquired Clostridioides difficile Infection Using Time-Trend Analysis

Background: In the past few decades, the epidemiology of Clostridioides difficile infection (CDI) has evolved. Given recent changes in the incidence of CDI and prevention efforts, we investigated temporal changes over a period of 8 years (2009–2016) in the incidence of and risk factors for CDI. Methods: Both pediatric and adult inpatients discharged from hospitals in metropolitan New York City were included. Individual and environmental (eg, pharmacological) risk factors were identified through a matched case-control by the length of stay at a ratio of 1:4. A Cochran–Armitage test or Mann-Kendall test was used to investigate trends of incidence and risk factors. Results: During the study period, 6,038 of 694,849 (0.87%) patients had a positive test for C. difficile during their hospitalization. Of these, 2,659 of 6,038 (44.04%) were identified as hospital-acquired CDI (HA-CDI) and just over half (3,379 of 6,038, 55.96%) were identified as community-acquired CDI (CA-CDI). There were no trends in total CDI incidence rates; rather, we detected downward trends in HA-CDI and upward trends in CA-CDI (Ptrend < .05). Younger patients and patients with lower risk of illness had HA-CDI over time (Ptrend < .05). Antibiotics were administered to more patients over time and in longer cumulative days (+3% and +3.1% per year). We detected a reduction in the receipt of high-risk antibiotics in all cohorts (−0.12% per year) and a decrease in cumulative days of high-risk antibiotics in the cohort with HA-CDI (−1.1% per year). When stratified by the type of high-risk antibiotics, the use of carbapenem, cephalosporins, clindamycin, and monobactam increased (+0.53%, +1.8%, +0.5%, and +0.39% per year, respectively), whereas the use of broad-spectrum penicillins and glycylcycline significantly decreased over time in all cohorts (−1.8% and −0.22% per year). Among the cohorts with HA-CDI, only cephalosporins showed a significant upward trend (+ 5.7% per year) and only fluoroquinolones showed a significant downward trend (−2.2% per year). Lastly, a reduction of proton pump inhibitors and an increased use of histamine-2 blockers were detected in all cohorts (−3.8% and +7.3% per year) (all Ptrend < .05). Conclusions: Although the incidence of HA-CDI decreased, more effort to decrease all antibiotics use and cumulative days should be emphasized as part of antibiotic stewardship. The downward trends of high-risk antibiotics might have been associated with the decrease in the trend of HA-CDI; however, the impact of the trends of risk factors on the trend of HA-CDI should be further investigated.Funding: NoneDisclosures: None

S0179 Role of Oral Vancomycin Prophylaxis in Preventing Recurrent Clostridioides difficile Infection in Hospitalized Patients Requiring Antibiotics: A Randomized Controlled Trial

INTRODUCTION: Clostridioides Difficile Infection (CDI) is a common health-care associated infection causing significant morbidity and mortality. There has been a dramatic increase in the incidence and severity of CDI due to emergence of NAP1 strain, use of broad-spectrum antibiotics, PPIs, and prolonged hospitalization with 1-3 month recurrence rates of around 25%. There are currently no evidence-based guidelines describing the role of oral vancomycin prophylaxis (OVP) to prevent recurrent CDI, thus accounting for the wide variation in practice. We aimed to evaluate the efficacy of OVP in reducing recurrence of CDI in hospitalized patients receiving antibiotics with a prior history of CDI, via a single-center randomized controlled trial. METHODS: Study was commenced following IRB approval in March 2018. Primary objective was to evaluate the efficacy of OVP in reducing recurrence of CDI in in-patients with prior CDI and receiving antibiotics. Secondary goal was to determine the differences in rate of recurrent CDI stratified by various CD inducers, dose of OVP, NAP1 strain, concurrent PPI use, time interval from prior CDI and pre-existing risk factors. We randomized in-patients receiving antibiotics, with prior CDI, to one of three arms in a 1:1:1 ratio following inclusion and exclusion criteria. Group A, B and C received oral vancomycin 125 mg daily, 125 mg twice-daily and no oral vancomycin respectively. OVP was given until the completion of antibiotics for primary infection. Patients were evaluated 12 weeks following completion of OVP using a standardized questionnaire. RESULTS: 109 patients were randomized with zero rate of recurrence in all groups. Secondary objectives could not be determined due to null recurrence. Death due to causes unrelated to CDI was noted in 10.1% of the entire cohort, of which 5.1% occurred in treatment groups while 5% occurred in control group. Three or more episodes of diarrhea was reported by 18.2% patients during follow-up; 12.2% were among treatment groups. CONCLUSION: Our results indicate no difference in recurrence rates between treatment and control groups. Based on our data, lack of recurrent CDI in our facility could be related to the rigorous antibiotic stewardship program initiated prior to the commencement of this study, low incidence of NAP-1 strain in our study cohort, as well as a new immunoassay for toxin detection which distinguishes between CD colonization from active CDI.

Machine-Learning Accurately Predicts Adverse Outcomes Following Clostridioides difficile Infection in Colorectal Surgery

Background:Clostridioides difficile infection (CDI) following colorectal surgery can lead to significant adverse outcomes. Although previous studies have identified risk factors for CDI, their relative importance for predicting complications remains unclear. Objective: We sought to use machine-learning algorithms to accurately determine which perioperative risk factors are most predictive of adverse outcomes after CDI. Methods: The National Surgical Quality Improvement Project (NSQIP) database was used to identify all patients who developed CDI after a colorectal operation in 2016 (N = 14,392). We excluded patients without CDI and patients <18 years of age. Any missing data were replaced with multivariate singular value decomposition imputation. We collected data on patient demographics, comorbidities, preoperative laboratory values, operative details, and outcomes, including infectious, cardiovascular, hematologic, renal, and pulmonary complications, unplanned returns to the operating room (RTOR), non–home discharge, readmission, and mortality. Data were univariably assessed for significant association with outcomes. If an input variable significantly correlated with ≥5 outcomes, it was included in our machine-learning models. We utilized bootstrap aggregation with random forests to improve prediction accuracy. We then calculated each input variable’s importance to the model outcome (VIP). The VIPs of each variable were averaged to yield an overall impact. Each model’s accuracy was determined by the area under the receiver operator curve (AUROC). Results: There were 841 patients in our cohort (median age 66 years (IQR, 55–75.8), 482 (57%) were women, and the mean American Society of Anesthesiologists [ASA] class score was 2.9 (SD, ±0.7). Of all colorectal surgeries, 172 (20.5%) were emergent. Overall mortality was 3.8% (n=32), and 371 patients (44.1%) experienced at least 1 postoperative complication, of which infectious complications (eg, septic shock, sepsis, wound infection, urinary tract infection) were most common (n=255, 30.3%). The RTOR rate was 10.3% (n = 87), the non–home discharge rate was 23.8% (n = 200), and the readmission rate was 30.9% (n = 260). The input variables most predictive of any adverse outcome were hematocrit (VIP, 24.9%), ASA class (VIP, 24.4%), creatinine (VIP, 17.4%), and prealbumin (VIP, 11.6%). The probability of any adverse outcome was 90.6% in the setting of hematocrit ≤27%, ASA class ≥3, creatinine ≥1.6 mg/dL, and prealbumin ≤3.1 mg/dL. All machine-learning models had an AUROC ≥0.99. Conclusions: Although nonpatient factors can contribute to unfavorable outcomes in patients with CDI following colorectal surgery, we identified 4 patient-specific variables that account for almost 80% of any adverse outcomes. Although further prospective study is needed, individuals with these preoperative risk factors could consider delaying their elective colorectal operations until they are medically optimized.Funding: NoneDisclosures: None

S0829 Vitamin D Deficiency Associated With Clostridioides difficile Infection in Inflammatory Bowel Disease Admissions: Insights From the National Inpatient Sample Database

INTRODUCTION: Clostridioides difficile infection (CDI) is an important cause of morbidity and mortality in inflammatory bowel disease (IBD) population. Well established risk factors for CDI include recent hospitalization, long term use of antibiotics, and chronic immunosuppression. Additionally, recent reports suggest that vitamin D-deficiency plays an important role in CDI susceptibility. This study aimed to evaluate the relationship between vitamin D deficiency and CDI in patients admitted with IBD exacerbation. METHODS: We queried the National Inpatient Sample database 2006–2014. We selected patients with a primary diagnosis of ulcerative colitis (UC), Crohn’s disease (CD), or IBD-related complications using the appropriate ICD-9 codes. We identified patients with the diagnosis of intestinal CDI. Categorical variables were compared using Chi-square. Predictors of Vitamin D deficiency and CDI were evaluated by multivariate logistic regression. RESULTS: A total of 1,000,218 weighted discharges with a primary diagnosis of UC, CD, or IBD-related complications were analyzed. 36.3% of the cases had UC, 64% had CD and 0.7% had undetermined IBD. Among all the cases 6.1% had a diagnosis of CDI. Patients with CDI were older (53.8 years vs 45.9 years, P < 0.001) and predominantly female (59.5% vs 40.5% P < 0.001). Older age, female gender (aOR: 1.18, P < 0,001), diagnosis of UC, vitamin D deficiency (aOR: 1.73, P < 0,001), long-term use of steroids (aOR: 1.2, P < 0,001), and antibiotics (aOR: 3.02, P < 0,001) were independent predictors of CDI among the IBD population. Patients with CD (aOR: 0.66, P < 0,001), long-term use of ASA (aOR: 0.93, P = 0.006) and non-steroidal anti-inflammatory drugs (aOR:0.52, P < 0,001) were less likely to have CDI during hospitalization. CONCLUSION: Vitamin D is involved in innate and acquired immunity and plays an important role on gut health. The deficiency of vitamin D in IBD patients has been associated with increased disease activity and poor outcomes. Only a few studies have examined an association between vitamin D levels and susceptibility to CDI in the IBD population. The proposed mechanism is decreased levels of cathelicidin, an antimicrobial peptide that inhibits the effect of C difficile toxin, which production is stimulated by vitamin D. Our study showed that vitamin D deficiency is a predictor of CDI in patients admitted with IBD exacerbation. Its main implication is the potential impact vitamin D supplementation can play in reducing the rates of CDI among the IBD population.Figure 1.: Percentages of the type of IBD among discharges for IBD exacerbation from 2006 to 2014.Table 1.: Summary of demographic characteristics of all cases with a primary discharge diagnosis of IBD: Nationwide Inpatient Database from 2006 to 2014Table 2.: Independent predictors of CDI in patients with a primary discharge diagnosis of IBD: multivariate logistic regression analysis in the Nationwide Inpatient Database in 2006–2014

Durability of Response to Fecal Microbiota Transplantation After Exposure to Risk Factors for Recurrence in Patients With Clostridioides difficile Infection.

Fecal microbiota transplantation (FMT) is highly effective for preventing recurrent Clostridioides difficile infection (CDI). Durability (no recurrence despite additional risk factor exposure) of FMT protection is largely unknown. We studied the durability of FMT in patients with recurrent CDI. We conducted a retrospective study of adults undergoing FMT for recurrent CDI. Data collected included demographics, CDI risk factors (comorbidities, healthcare exposure, non-CDI antibiotic use, acid suppressant medications), and future CDI episodes. Durable response to FMT was defined as lack of CDI episodes within 1 year post-FMT despite risk factor exposure. Overall, 460 patients were included (median age, 57 years [18-94]; 65.2% female). Comorbidities included chronic liver disease, 12.8% (n = 59); cancer, 11.7% (n = 54); chronic kidney disease, 3.9% (n = 18); and inflammatory bowel disease, 21.9% (n = 101). Overall, 31.3% (n = 144) received antibiotics, 21.7% (n = 100) received acid suppressants, and 76.8% (n = 350) had healthcare exposure after FMT. Of 374 patients with risk factor exposure, 78.1% (95% confidence interval [CI], 72.7%-84.0%) had durable response to FMT at 1 year. On multivariable analysis, antibiotic use was independently associated with decreased durability of FMT (hazard ratio, 0.27; 95% CI, .15-.49; P < .001). The majority of patients had a durable response to FMT despite exposure to CDI risk factors. Antibiotic exposure after FMT independently predicted loss of durability of FMT. Larger studies are needed to define predictors of durable response in patients with and without exposure to antibiotics.

Healthcare-associated Urinary Tract Infection (HA-UTI): A Risk Factor for Clostridioides Difficile Infection (CDI)? Results of a Real-world Data (RWD) Analysis

<h3>Background</h3> It is estimated that 223,900 cases of CDI occur annually in hospitalized patients resulting in 12,800 deaths and $1 billion in attributable costs. Antimicrobial use is a risk factor for CDI. Antimicrobials ordered for UTI have been identified as a factor in both recurrent CDI and community-acquired CDI. This RWD analysis seeks to explore the relationship between HA-UTI and hospital-onset CDI (HO-CDI). <h3>Methods</h3> An electronic infection surveillance system was the source of de-identified RWD from 290 hospitals. Algorithmically-derived measures of healthcare-associated infections (ADM-HAIs), and records of all-cause antimicrobial orders (AOs), for all inpatient admissions for the period 10/1/18–9/30/19 were analyzed. All patients who presented with a urine ADM-HAI suggestive of HA-UTI and no other healthcare-associated infection (Urine+ patients), were observed for subsequent HO-CDI. Urine+ patients were compared to patients with no HAI of any type, other than CDI (HAI-free patients), and relative risk (RR) was estimated. The analysis was repeated for the subgroup of patients who received an AO for any reason during their stay. <h3>Results</h3> 3,050,525 inpatient admissions were analyzed. 26,634 were identified as Urine+ patients. 188 of those patients subsequently presented with HO-CDI. 2,978,507 were identified as HAI-free patients. 6,238 of those patients presented with HO-CDI. The incidence of HO-CDI was significantly higher in Urine+ patients compared to HAI-free patients (RR=3.37, 95% CL[2.92, 3.89], p<0.0001). When the analysis was repeated to examine only patients who received AOs, Urine+ patients continued to be at higher risk of subsequent HO-CDI compared to HAI-free patients (RR=3.28, 95% CL[2.74,3.92], p<0.0001). <h3>Conclusions</h3> The presence of a urine ADM-HAI, suggestive of HA-UTI, was associated with an increased risk of subsequent HO-CDI. This held when only patients with AOs were considered. These observations mirror findings from other published studies, however, other factors may have contributed to increased risk for both HA-UTI and HO-CDI.

Incidence and Risk Factors of Recurrent Clostridioides difficile Infection in Patients With Cirrhosis.

INTRODUCTION:Clostridioides difficile infection (CDI) is common in patients with cirrhosis and is associated with poor outcomes. CDI risk factors in this population have been well characterized; however, risk factors of recurrent CDI (R-CDI) after treatment have not been explored. We sought to estimate the incidence of R-CDI and its associated risk factors in patients with cirrhosis.METHODS:We performed a cohort study of patients with cirrhosis hospitalized with CDI between 2012 and 2016. We collected patient characteristics, including detailed information on the CDI, features of the underlying liver disease, and outcomes including R-CDI, hospital readmission, and mortality. R-CDI was defined as CDI occurring 2–8 weeks after the initial episode. Cox proportional hazards model was used to identify variables independently associated with the outcomes.RESULTS:A total of 257 hospitalized patients with cirrhosis and CDI were included. CDI was community associated in 22.6%. The incidence of R-CDI was 11.9%. R-CDI was not significantly associated with medications at hospital admission or discharge. Independent risk factors of R-CDI included increased Charlson Comorbidity Index (hazard ratio [HR] 1.30; 95% confidence interval [CI]: 1.09–1.55) and use of lactulose (HR 2.58; 95% CI: 1.09–6.09). The 30-day readmission rate was 37%, and readmission was associated with increased Charlson Comorbidity Index (HR 1.12; 95% CI: 1.03–1.23) and Model for End-Stage Liver Disease score (HR 1.04; 95% CI: 1.01–1.07). The 90-day mortality was 22.8%.DISCUSSION:In patients with cirrhosis, R-CDI is associated with comorbidity burden and lactulose use. Attention to these factors might aid clinicians in efforts to prevent R-CDI and improve outcomes in this population.

Hospital acquired Clostridioides difficile infection and risk factors for severity in a university hospital: A prospective study

Clostridioides difficile infection (CDI) is a well-known cause of health care-associated diarrhea. Data about CDI epidemiology of Turkey is limited. This study investigates CDI incidence, clinical characteristics, and factors associated with severe CDI in a tertiary care center university hospital. This is a case control study was conducted between 2012 and 2016. We included all patients, 18 years of age or more, with CDI diagnosis. For each patient diagnosed with CDI, information was collected concerning the severity of disease, treatment regimen, treatment response, disease recurrence, 30-day case fatality. Cases defined as severe hospital acquired CDI (HA-CDI) and controls defined as non-severe CDI patients. We identified 100 cases of HA-CDI out of 111 patients. Total CDI incidence was 1.19/10,000 patient-days. The incidence decreased 32.5% during the study period. We identified severe CDI in 24% of patients. Age and admission to intensive care unit were independent risk factors for severe CDI. This study reports a 5-year prospective epidemiology of CDI in a tertiary care center in Istanbul, Turkey. The findings of this study suggest that HA-CDI incidence and proportion of severe CDI is low compared to European and US literature. We believe that CDI is underreported, neglected but still an important health care associated infection in Turkey.

Clostridioides difficile infection after pneumonia in elderly patients: which antibiotic is at lower risk?

Clostridioides difficile infection (CDI) is a frequent and severe complication of antibiotic treatment in older patients hospitalized for acute pneumonia (AP). We aimed to assess the burden and risk factors of CDI and to determine which of the usual antibiotics regimens is at lower risk for post-AP CDI incidence. Among patients aged >75y hospitalized for AP in all departments of a university hospital between 2007 and 2017, all the 92 patients developing a CDI were compared with 213 patients without CDI. Factors associated with 1) in-hospital and one-year mortality, 2) CDI incidence were assessed using logistic regression models. In patients with and without CDI after AP, mortality rates were respectively at 34% vs 20% in hospital and 63% vs 42% at one-year. After adjustment for confounders, CDI was associated with a two-fold risk of in-hospital and one-year mortality after pneumonia (Respective Odds Ratio (95% Confidence Interval), OR (95%CI): 1.95 (1.06-3.58) and 2.02 (1.43-7.31)). High number of antibiotics (Per antibiotic, OR (95%CI): 1.89 (1.18-3.06)), rather than antibiotics duration (Per day, OR 95%CI): 1.04 (0.96-1.11)) was associated with a higher risk of CDI. Compared with other antibiotics, use of penicillin + beta-lactamase inhibitors was associated with a lower risk of CDI (OR (95%CI): 0.43 (0.19 -0.99)) CONCLUSION: In older inpatients, CDI highly increase the burden of AP at both short and long term. If confirmed, these results suggest the preferential use of penicillin + beta-lactamase inhibitors for a lower incidence of CDI in older inpatients with AP.

Antibiotic Exposure and Risk for Hospital-Associated Clostridioides difficile Infection.

Clostridioides difficile infection (CDI) is a health care-associated infection associated with significant morbidity and cost, with highly varied risk across populations. More effective, risk-based prevention strategies are needed. Here, we investigate risk factors for hospital-associated CDI in a large integrated health system. In a retrospective cohort of all adult admissions to 21 Intermountain Healthcare hospitals from 2006 to 2012, we identified all symptomatic (i) hospital-onset and (ii) health care-facility-associated, community-onset CDI. We then evaluated the risk associated with antibiotic exposure, including that of specific agents, using multivariable logistic regression. A total of 2,356 cases of CDI among 506,068 admissions were identified (incidence, 46.6 per 10,000). Prior antibiotic use was the dominant risk factor, where for every antibiotic day of therapy prior to the index admission, the odds of subsequent CDI increased by 12.8% (95% confidence interval [CI], 12.2 to 13.4%; P < 0.0001). This was a much stronger association than was inpatient antibiotic exposure (odds ratio [OR], 1.007 [95% CI, 1.005 to 1.009]; P < 0.0001). The highest-risk antibiotics included second-generation and later cephalosporins (especially oral), carbapenems, fluoroquinolones, and clindamycin, while doxycycline and daptomycin were associated with a lower CDI risk. We concluded that cumulative antibiotic exposure prior to admission is the greatest contributor to the risk of subsequent CDI. Most classes of antibiotics carry some risk, which varies by drug and route. This information may be useful for antimicrobial stewardship efforts.

A multicenter study to define the epidemiology and outcomes of Clostridioides difficile infection in pediatric hematopoietic cell and solid organ transplant recipients.

Hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients are at increased risk for Clostridioides difficile infection (CDI). We conducted a multicenter retrospective study to describe the incidence of CDI in children transplanted between January 2010 and June 2013. Nested case-control substudies, matched 1:1 by transplant type, institution, patient age, and time of year (quartile) of transplant, identified CDI risk factors. Cohorts included 1496 HCT and 1090 SOT recipients. Among HCT recipients, 355 CDI episodes were diagnosed in 265 recipients (18.2%). Nested case-control study identified prior history of CDI (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5-4.7), proton pump inhibitors (PPIs; OR 2.1, 95% CI 1.3-3.4), and exposure to third- (OR 2.4, 95% CI 1.4-4.2) or fourth-generation (OR 2.1, 95% CI 1.2-3.7) cephalosporins as risk factors. Notably, fluoroquinolone exposure appeared protective (OR 0.6, 95% CI 0.3-0.9). Ninety-two episodes of CDI were diagnosed among 79 SOT recipients (7.3%), and exposure to PPIs (OR 2.4, 95% CI 1.1-5.4) and third-generation cephalosporin therapy (OR 3.9, 95% CI 1.4-10.5) wereidentified as risk factors. Strategies to decrease PPI use and changes in the class of prophylactic antibiotics may impact CDI incidence and warrant further study.

Clostridioides difficile associated peritonitis in peritoneal dialysis patients \u2013 a case series based review of an under-recognized entity with therapeutic challenges

BackgroundInitial presentation of peritoneal dialysis associated infectious peritonitis can be clinically indistinguishable from Clostridioides difficile infection (CDI) and both may demonstrate a cloudy dialysate. Empiric treatment of the former entails use of 3rd-generation cephalosporins, which could worsen CDI. We present a logical management approach of this clinical scenario providing examples of two cases with CDI associated peritonitis of varying severity where the initial picture was concerning for peritonitis and treatment for CDI resulted in successful cure.Case presentationA 73-year-old male with ESRD managed with PD presented with fever, abdominal pain, leukocytosis and significant diarrhea. Cell count of the peritoneal dialysis effluent revealed 1050 WBCs/mm3 with 71% neutrophils. C. difficile PCR on the stool was positive. Patient was started on intra-peritoneal (IP) cefepime and vancomycin for treatment of the peritonitis and intravenous (IV) metronidazole and oral vancomycin for treatment of the C. difficile colitis but worsened. PD fluid culture showed no growth. He responded well to IV tigecycline, oral vancomycin and vancomycin enemas. Similarly, a 55-year-old male with ESRD with PD developed acute diarrhea and on the third day noted a cloudy effluent from his dialysis catheter. PD fluid analysis showed 1450 WBCs/mm3 with 49% neutrophils. IP cefepime and vancomycin were initiated. CT of the abdomen showed rectosigmoid colitis. C. difficile PCR on the stool was positive. IP cefepime and vancomycin were promptly discontinued. Treatment with oral vancomycin 125 mg every six hours and IV Tigecycline was initiated. PD fluid culture produced no growth. PD catheter was retained.ConclusionsIn patients presenting with diarrhea with risk factors for CDI, traditional empiric treatment of PD peritonitis may need to be reexamined as they could have detrimental effects on CDI course and patient outcomes.

Clostridioides difficile Infections in Adult and Pediatric Intestinal and Multivisceral Transplant Patients

Background Solid organ transplant (SOT) recipients are at increased risk of Clostridioides difficile infection (CDI). Studies addressing the epidemiology of CDI in intestinal and multivisceral transplant are limited. Since 2013, our center greatly expanded its intestinal and multivisceral transplant program, providing the consummate opportunity to examine CDI in this vulnerable population. Methods We conducted a retrospective study of all intestinal and multivisceral transplant recipients between 2009 and 2018. Results We identified 86 patients who underwent a total of 94 transplants. There were 60 isolated intestinal transplants (64%), 21 intestine/pancreas/liver (22%), 10 intestine/pancreas (11%), 2 intestine/pancreas/liver/kidney (2%), and 1 intestine/kidney transplant (1%). All but 3 patients received perioperative metronidazole. Four patients (5%) had CDI before transplant, but none experienced recurrence in the first 6 months posttransplant. Five patients suffered 7 mild-moderate episodes of early CDI (attack rate, 5.9%). Three patients (60%) with early CDI developed rejection, similar to the observed incidence (70%) in patients without CDI. Two patients with early CDI developed recurrent infection; both of these patients underwent intestinal retransplant. Overall, 1-year mortality was similar (20% among patients with early CDI vs. 23% among those without early CDI). Conclusions For certain solid organ transplant recipients, an association between CDI and allograft loss, rejection, and mortality has been shown. Although limited by sample size, we observed that early CDI was not associated with those outcomes in the present investigation. Multicenter studies are merited to explore risk factors for CDI and associations with transplant-related outcomes in intestinal and multivisceral transplant recipients.

Recommendations and guidelines for the treatment of Clostridioides difficile infection in Taiwan.

Clostridioides difficile infection (CDI) is a major enteric disease associated with antibiotic use and a leading cause of hospital-acquired infections worldwide. This is the first guideline for treatment of CDI in Taiwan, aiming to optimize medical care for patients with CDI. The target audience of this document includes all healthcare personnel who are involved in the medical care of patients with CDI. The 2018 Guidelines Recommendations for Evidence-based Antimicrobial agents use in Taiwan (GREAT) working group was formed, comprising of infectious disease specialists from 13 medical centers in Taiwan, to review the evidence and draft recommendations using the grading of recommendations assessment, development, and evaluation (GRADE) methodology. A nationwide expert panel reviewed the recommendations during a consensus meeting in March 2019. The recommendation is endorsed by the Infectious Diseases Society of Taiwan (IDST). This guideline describes the epidemiology and risk factors of CDI, and provides recommendations for treatment of CDI in both adults and children. Recommendations for treatment of the first episode of CDI, first recurrence, second and subsequent recurrences of CDI, severe CDI, fulminant CDI, and pediatric CDI are provided.

Outcome of Clostridioides difficile infections treated in a Swiss tertiary care hospital: an observational study.

Clostridioides difficile infection (CDI) is associated with high morbidity, recurrence rates and mortality. We assessed the local epidemiology, treatment outcomes and risk factors for recurrence and mortality. This was a retrospective study of all adult CDI episodes treated in our tertiary care hospital between 2014 and 2016. Patients were followed up for 60 days, with recurrence and death as endpoints. Antibiotic treatment as well as epidemiological, clinical and laboratory parameters were studied using logistic regression analysis. Risk factors for recurrent CDI (age &gt;70 years, haematological malignancy, chronic kidney disease, severe infection, continued antibiotics other than for CDI, proton pump inhibitor / antacid use) and indicators of severe CDI (temperature &ge;38.5&deg;C, leucocytes &gt;15 &times; 109/l, creatinine increase &ge;1.5 &times; baseline, albumin &lt;25 g/l) were analysed. We considered episodes with &ge;2 indicators as severe. We identified 210 CDI episodes (66 severe) in 191 patients with a median age of 71 years (interquartile range 59&ndash;79). Hypervirulent ribotype 027/NAP1/BI accounted for four episodes (2%). Overall, 176, 30 and 4 patients, respectively, received a first, second and third treatment. Metronidazole was used in 94% of the first episodes and in 73% and 50% of the first and second recurrences, respectively. The recurrence rate after the first metronidazole treatment was 20%. Recurrence rates were higher when &ge;2 risk factors were present (25 vs 10%, p = 0.03). The 60-day mortality was 17% (4% attributable to CDI) and increased with the presence of &ge;2 indicators of severe CDI. The high 60-day mortality suggests that CDI is a strong indicator of frailty. Metronidazole was associated with low recurrence rates at minimal costs in patients with uncomplicated CDI, but had relevant shortcomings in patients with severe CDI and/or a high risk of recurrence, suggesting that these vulnerable patients might better be treated with oral vancomycin and fidaxomicin, according to the latest guidelines. &nbsp.

Clostridioides Difficile Infection Is a Rare Cause of Infectious Pouchitis

Introduction: The true incidence of Clostridioides difficile infection (CDI) in patients with an ileal pouch is unknown, and there is little published on its associated risk factors. Objective: We aimed to evaluate the rate and risk factors of CDI in pouch patients. Methods: This was a retrospective review conducted at a single tertiary care inflammatory bowel disease (IBD) center. All ulcerative colitis or IBD-unspecified (IBD-U) patients who underwent total proctocolectomy with ileal pouch anal anastomosis for medically refractory disease or dysplasia between 2008 and 2017 were identified. Symptomatic patients tested for CDI were included. Demographic, disease, and surgical characteristics were collected. Nonparametric methods were used to compare continuous outcomes, and χ² and Fisher’s exact tests were used to compare patients with and without CDI as appropriate. Results: A total of 154 pouch patients had postoperative C. difficilestool testing for symptoms of fever, urgency, increased stool frequency, hematochezia, incontinence, and abdominal and/or pelvic pain. CDI was diagnosed in 11 (7.1%) patients a median of 139 days (IQR 34–1,170) after the final surgical stage. Ten patients (90.9%) received oral vancomycin for 10 days and 1 patient (9.1%) received oral metronidazole for 2 weeks. Ten patients (90.9%) reported improvement in symptoms at completion of therapy. Nine patients (81.8%) were retested for CDI for recurrent symptoms and found to be negative. No patient had CDI recurrence. There was no significant difference in demographic and surgical characteristics, previous antibiotic or proton pump inhibitor use, or previous hospital admission among the patients with and without CDI. Conclusions: CDI is a rare cause of infectious pouchitis and treatment with oral vancomycin improves symptoms.

I]Clostridioides difficile[/i] infection in patients with end stage renal disease. Is it preventable?

[i]Clostridioides difficile[/i] infection (CDI) is a leading cause of a healthcare-associated diarrhea worldwide. Recently, an increased number of new cases and growing mortality due to CDI have been observed. Patients suffering from end-stage renal disease (ESRD) are most exposed to CDI. It has been proven that CDI in patients receiving renal replacement therapy (RRT) significantly increases mortality, prolongs hospitalization and increases the cost of treatment. Important risk factors of CDI in ERSD patients include hospitalization or stay in an intensive care unit in the last 90 days, HIV infection, bacteremia, prolonged antibiotic therapy and hypoalbuminemia. Cirrhosis, age over 65 years, hypoalbuminemia, longer hospitalization time and use of antibiotics are significant risk factors of death. Effective methods of preventing CDI include hand hygiene with soap and water, isolation of infected patients in a private room with a dedicated toilet, the use of masks, gloves, disinfection of the environment and systematic education and control of medical personnel, as well as rational antibiotic policy. In addition, it is important to avoid antibiotics with a proven risk of CDI, caution use of proton pump inhibitors (PPI) and H2 receptor antagonists. It is also important in the prevention of CDI in people with ERSD, to apply a fast diagnostic since the onset of the first symptoms. The use of probiotics and bile acids in the primary prevention of CDI requires further research. It seems that knowledge of these factors and methods of prevention will significantly reduce morbidity and mortality due to CDI.

Outcomes of Clostridioides difficile Infection in Patients With Liver Cirrhosis: A Nationwide Study.

BackgroundClostridioides difficile infection (CDI) is a major health problem that has been on the rise for the last couple of decades. It has significant mortality and morbidity in hospitalized patients. We looked at the outcomes of CDI in patients with liver cirrhosis compared to those without liver cirrhosis.MethodsWe conducted a retrospective study from a large inpatient database. The National Inpatient Sample (NIS) was queried for CDI admissions between January 2012 and September 2015. Patients admitted with CDI were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The outcomes included overall mortality, length of hospitalization, and healthcare expenditure related to hospitalization.ResultsOut of all patients, 53,765 (3.97%) had concurrent CDI and liver cirrhosis. Diabetes mellitus, alcohol abuse, and acquired immunodeficiency were observed more in patients with liver cirrhosis. Overall mortality (adjusted odds ratio (aOR) 1.65, 95% confidence interval (CI) 1.53 - 1.77, P < 0.001), cost of hospitalization and length of hospital stay (11.0 vs. 10.4 days, P < 0.001) were significantly higher in patients with cirrhosis.ConclusionsPatients with CDI and liver cirrhosis have significantly higher mortality, prolonged hospitalization and healthcare expenditure. Further studies are recommended to look at reversible risk factors for CDI in patients with liver cirrhosis to guide quality measures that would ultimately improve outcomes.

Incidence, outcome, and risk factors for recurrence of nosocomial Clostridioides difficile infection in adults: A prospective cohort study

BackgroundNosocomial Clostridioides difficile infection (CDI) complicates up to 1% of all hospital admissions and is associated with considerable health burden. AimsTo determine the incidence and outcomes of nosocomial CDI at a major University Medical Center. MethodsConsecutive adult nosocomial CDI cases were prospectively identified. Stool samples were collected for ribotyping and antibiotic resistance testing. Patients were followed for eight weeks after discharge for relapse. ResultsOver a 2-year period, 215 patients developed nosocomial CDI (incidence 2:1000) and 200 (mean age 62.2±19.6 years) gave informed consent. Mean hospital stay was 23.3±28.9 days (range 0–278). Infection was diagnosed within 7 days of admission (range 0–95) in 129 patients (64.5%). More than two-thirds (69.0%) were previously hospitalized within 12 weeks of the index hospitalization. Twenty five percent received prior antibiotics within eight weeks. Fifty-two patients (26.0%) did not receive antibiotics prior to diagnosis. Considerable comorbidities (Charlson Comorbidity Index ≥8) were noted in 33.5% of patients. Recurrence occurred in 43 patients (21.5%). On multivariate logistic regression, fluoroquinolone exposure was the only predictor of recurrence (OR=2.9, 95%CI 1.1–7.7). Overall mortality was 14.0% and CCI ≥8 was the only predictor on multivariate analysis (p=0.004). Genotyping did not identify any known hypervirulent strains and all isolates were susceptible to metronidazole and vancomycin. ConclusionAntibiotic exposure, comorbidities, and prior hospitalization constitute the major risk factors for nosocomial CDI. Recurrence is common and is associated with fluoroquinolones exposure. High baseline comorbidity score was the only predictor of increased mortality in this prospective cohort.