Risk Of Clostridium Difficile Infection Research Articles

Helicobacter pylori Eradication Treatment in Older Patients.

Helicobacter pylori is the main etiopathogenetic factor of chronic gastritis, peptic ulcer disease and gastric cancer. The world's population is shifting towards older people, who have the highest prevalence of H. pylori. Aging-related peculiarities could have an impact on the treatment of H. pylori and there is still a lack of research data in the older population. The aim of this review was to summarize the findings of the most recent information, publications and studies on the issues relating to H. pylori infection in older patients. H. pylori eradication offers gastrointestinal and extra gastrointestinal benefits in older patients. Based on the main guidelines, H. pylori should be eradicated independent of the patient's age, only reconsidering cases with terminal illness and low life expectancy. Proton pump inhibitors are generally safe and well tolerated. Some antibiotics require dose adjustment only in advanced renal insufficiency and the risk of hepatotoxicity is very low. Special precautions should be taken in patients with polypharmacy and those taking aspirin or non-steroidal anti-inflammatory drugs. In older patients, H. pylori eradication treatment frequently causes only mild and short-term adverse events; however, treatment compliance is usually still very good. H. pylori treatment in older patients does not increase the risk of Clostridium difficile infection. Optimal eradication effectiveness (>90%) is mostly achieved with bismuth- and non-bismuth-based quadruple therapies. Susceptibility-guided treatment of H. pylori can contribute to increasing the effectiveness of eradication regimens in older adults. To achieve optimal H. pylori eradication effectiveness in older patients, the same guidelines, which are applied to adults, also apply to this population: avoiding repetitive treatment prescriptions, choosing quadruple therapies, prescribing longer treatment duration and administering high-dose proton pump inhibitors twice daily.

Association Between Risk of Clostridium difficile Infection and Duration of Proton Pump Inhibitor or H2-Receptor Antagonist Use in Hospitalized Patients.

Limited studies have evaluated the association between Clostridium difficile infection (CDI) and the duration of proton pump inhibitor (PPI) or histamine H2-receptor blocker (H2RA) use and provided a cutoff duration for PPI or H2RA use to mitigate a substantially increased risk of CDI. We aimed to evaluate these associations in hospitalized patients using a nationwide insurance claims database. We conducted a nested case-control study to identify cases with a first ever record of CDI in a study cohort undergoing PPI or H2RA therapy from the National Health Insurance Database from 2012 to 2018. Each case was matched with one control by age, sex, and calendar year. We used conditional logistic regression to estimate the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC ROC). Youden's Jstatistic was used to identify the optimal cutoff duration in days for PPI or H2RA use. In the main analysis, the AUC ROC was 0.64 (95%CI 0.63-0.66) and optimal cutoff duration was 15days for PPI users. The AUC ROC was 0.63 (95%CI 0.62-0.64) and optimal cutoff duration was 16days for H2RA users. In the sensitivity analyses, the results were similar to those of the main analysis, and the optimal cutoff duration was in the range of 14-15days. The optimal cutoff duration for PPI and H2RA use was about 2weeks. It is necessary to be cautious regarding the risk of CDI in patients taking PPIs or H2RAs for longer than 2weeks.

Association of congestive heart failure (CHF) with incidence rates of enteric infections and gram-negative sepsis (GNS) in patients with hepato-pancreatico-biliary cancers (HPBCs).

567 Background: ChronicCHF leads to volume overload and can cause bowel wall edema. This may compromise local immune defense and promote increased translocation of gut bacteria into the blood.HPBCs can cause biliary tract obstruction which is also associated with bacteremia. Additionally, cancer treatments are associated with an increased risk of clostridium difficile infection (CDI), regardless of antibiotic exposure. While associations between cancer and increased infection rates are well-established, we questioned whether concomitant CHF increases this risk further in the HPBC population. We therefore investigated whether concomitant CHF and HPBC influenced CDI, other infectious gastroenteritis (IGE), GNS rates or all-cause-hospital mortality. Methods: A retrospective study was conducted by obtaining patients with HPBC through the application of specific ICD 10 codes from the National Inpatient Sample 2020, a large publicly available database of inpatient hospital stays incorporating data from hospitals across 48 U.S. states. Among this cohort, patients with chronic CHF were further identified by applying all CHF-specific ICD 10 codes. All patients with HPBC were divided into two groups, one with CHF (group A) and the other without CHF (group B). Outcomes were compared between the two groups using multivariate regression analysis (MVRA) adjusting for demographic factors, hospital-specific characteristics like location, bed size, etc., comorbidities including obesity, diabetes, hypertension, prior cardiovascular events, HIV, CKD, OSA, etc., prior coronary intervention/surgery as well as alcohol, smoking or substance use. Results: 211,790 patients were identified with HPBC. 40.55% were female. 18,955 patients (9.95%) were found to have chronic CHF. The incidence of GNS was higher in group A compared to group B in the MVRA (Adjusted (Ad) OR: 1.4, CI 1.07-1.95, p=0.015). However, there was no difference in the incidence rate of CDI between groups A and B (Ad OR: 1.0, CI 0.71-1.50, p=0.86). Similarly, the two groups had no difference in other IGE (Ad OR: 1.0, CI 0.71-1.37, p=0.96). All-cause hospital mortality was slightly higher in group A than group B but failed to reach statistical significance (Ad OR: 1.1, CI: 0.99-1.29, p=0.069). Conclusions: GNS was more common in patients with HPBC who also had comorbid chronic CHF. Future investigations may focus on the effect of increased GNS on outcomes beyond hospitalization, correlation between the severity of CHF and GNS as well as primary site of HPBC and infection risk. Based on this signal-finding analysis, it is postulated that early inter-disciplinary collaboration between oncology and cardio-oncology/cardiology may have special significance in the management of patients with chronic CHF and HPBCs, the latter of which already carries a dismal prognosis.

The Adverse Effects of Proton Pump Inhibitors and How to De-Escalate Therapy

This article discusses how many patients, both inpatient and outpatient, are initiated on proton pump inhibitors (PPIs) for stomach acid related symptoms, as well as for prophylaxis. These medications may inadvertently be continued long-term. Chronic use of PPIs can result in adverse events, such as vitamin deficiencies, community-acquired pneumonia, and an increased risk for Clostridium difficile infection. Clinicians should periodically evaluate the need for PPIs in patients and discontinue as appropriate.

Vedolizumab does not increase risk of clostridium difficile infection in patients with inflammatory bowel disease using vedolizumab: A retrospective cohort study

IntroductionSeveral studies have shown increased incidence, recurrence, and severity of Clostridium difficileinfection (CDI) over the last decade. Patients with inflammatory bowel disease (IBD) who develop CDI are more prone to morbidity and mortality than CDI in patients without IBD. This study seeks to evaluate whether IBD patients who use vedolizumab are at increased risk of CDI compared to IBD patients using other therapies. MethodsThis was a retrospective cohort study, and 684 patients with confirmed IBD (228 on vedolizumab, 228 on anti-TNF, and 228 on 5- Aminosalicylates acid therapy) were enrolled from January 2009 to August 2019 at a tertiary referral IBD center at McMaster University Medical Centre (MUMC) in Hamilton, Ontario, Canada. The primary outcome was time to the development of CDI in IBD patients using different therapies. Secondary outcomes included rates of CDI and the association between baseline variables and risk of CDI. A Cox proportional hazards (PH) model was used to evaluate baseline factors and development of CDI. ResultThere was no difference in time to CDI between the three treatment groups (log rank p-value 0.37). CDI occurred in 16 patients (2.3%), specifically four patients (1.75%) in the vedolizumab group, four patients (1.75%) in the anti-TNF group, and eight patients (3.5%) in the 5-ASA group. The Cox PH model found current smoking, older age, and concomitant immunomodulator use as risk factors for CDI, after adjustment for other covariates. Vedolizumab was not associated with increased risk of CDI in the model. ConclusionBiologic therapy with vedolizumab or anti-TNF did not impact risk of CDI. Risk factors for CDI in IBD patients included smoking, older age at the onset of medication, and immunomodulator therapy. Clinicians should have high degree of suspicion for CDI in IBD patients presenting with diarrhea, particularly in those with risk factors identified in this study.

Clostridium difficile Infection Risk Factors and Outcomes Among Inpatients Infected with NAP1/BI/027 Strain Compared to Non-NAP1 Strain in a Major Chinese Hospital

Background: NAP1/027 Clostridium difficile infection (CDI) has rarely been reported in China. Objectives: The objective of this study was to strengthen the understanding of the risk factors and outcomes of NAP1/027 CDI. Methods: A single-center, retrospective, case-control (1: 3) study was performed to identify risk factors and outcomes specific to NAP1/027 CDI using a group of patients with NAP1/027 CDI (n = 20) and a group of age-matched control patients with non-NAP1/027 CDI (n = 60) within June 2018 and August 2021. The patient charts were thoroughly reviewed to assess the markers of severity, risk factors, and outcomes. Results: Out of the 272 stool specimens, 41 cases (15.07%) tested positive for the NAP1 strain of C. difficile using the polymerase chain reaction. Among these specimens, 20 cases fulfilled the inclusion criteria. No significant difference was observed between the NAP1/027 and non-NAP1/027 groups in disease severity, length of hospital stay, or mortality. Logistic regression analysis revealed that risk factors for acquiring NAP1/027 infection included hospitalization in the 90 days before CDI diagnosis and high C-reactive protein level within ± 3 days of C. difficile detection. Conclusions: In a large non-epidemic tertiary hospital in China, NAP1/027 strains were more prevalent in patients with previous hospitalization and high CRP level than non-NAP1/027 strains.

Real-World Data in Pharmacovigilance Database Provides a New Perspective for Understanding the Risk of Clostridium difficile Infection Associated with Antibacterial Drug Exposure.

Antibacterial drug exposure (ADE) is a well-known potential risk factor for Clostridium difficile infection (CDI), but it remains controversial which certain antibacterial drugs are associated with the highest risk of CDI occurrence. To summarize CDI risk associated with ADE, we reviewed the CDI reports related to ADE in the FDA Adverse Event Reporting System database and conducted disproportionality analysis to detect adverse reaction (ADR) signals of CDI for antibacterial drugs. A total of 8063 CDI reports associated with ADE were identified, which involved 73 antibacterial drugs. Metronidazole was the drug with the greatest number of reports, followed by vancomycin, ciprofloxacin, clindamycin and amoxicillin. In disproportionality analysis, metronidazole had the highest positive ADR signal strength, followed by vancomycin, cefpodoxime, ertapenem and clindamycin. Among the 73 antibacterial drugs, 58 showed at least one positive ADR signal, and ceftriaxone was the drug with the highest total number of positive signals. Our study provided a real-world overview of CDI risk for AED from a pharmacovigilance perspective and showed risk characteristics for different antibacterial drugs by integrating its positive-negative signal distribution. Meanwhile, our study showed that the CDI risk of metronidazole and vancomycin may be underestimated, and it deserves further attention and investigation.

Comparison of outcomes of Clostridium difficile infection in autologous stem cell transplant recipients compared to allogenic stem cell transplant recipients.

e19064 Background: Hematopoietic stem cell transplant (HSCT) recipients are at a higher risk of clostridium difficile infection (CDI). The incidence of CDI in allogenic SCT recipients has been shown to be about 2-fold compared to autologous SCT recipients in certain studies. These differences can be attributed to myeloablative chemotherapy and increased duration of immunosuppression in allogenic SCT patients. In this study we evaluate the impact of CDI on in-hospital outcomes in these two groups of patients. Methods: We included all patients with a prior diagnosis or a procedure code for HSCT and CDI using ICD-10 codes from National Inpatient Sample 2016-2019. Patients were stratified into two groups based on the presence or absence of autologous stem cell transfusion. Information was collected regarding patient demographics, Charlson comorbidities, resource utilization (LOS and total hospitalization charges), and outcomes. The outcomes included sepsis, shock, acute kidney injury, ICU admission, and in-hospital mortality. The differences in outcomes between the two groups were studied. Results: The incidence of CDI in autologous stem cell transplant recipients was lower compared to the allogenic HSCT group (5.1% vs. 6.1%, p-0.003). 7,605 patients were included in the study. Of them, 2,460 (32.25%) patients had autologous stem cell transplantation, while the remaining had allogenic stem cell transfusion. A higher proportion of patients in the autologous stem cell transplant group were males (60.7% vs. 54.32%), and patients aged 45-64 years (55.7% vs. 46.4%). Patients who received autologous stem cell transplants had a lower incidence of death (1.6% vs. 7.8%, p < 0.001), sepsis (17.28% vs. 28.18%, p- < 0.001), shock (4.7% vs. 12%, p < 0.001), AKI (15% vs. 31.6%, p < 0.001) and ICU admissions (5.7% vs. 10.7%, p- < 0.001). There was no significant difference in the length of stay between the two groups (21.30 days vs 22.97 days). Patients in the autologous stem cell transplant group had lower hospitalization charges ($318,072.3 vs $402,281.5, p < 0.001) than the allogenic group. Conclusions: Like prior studies, our study is compatible with the lower incidence of CDI in autologous SCT recipients. Our study also suggested a lower in-hospital mortality and better outcomes compared to patients with allogeneic stem cell transplants. Resource utilization was also noted to be lower in autologous stem cell transplant patients. Further research should be conducted to explain the differences and to allow physicians to provide timely treatments to prevent worse outcomes.

The prevalence and clinical characteristics of Clostridium difficile infection in Saudi patients admitted with inflammatory bowel disease: A case-control study.

Inflammatory bowel disease (IBD) patients are at increased risk of Clostridium difficile infection (CDI), causing significant morbidity and mortality. This study examined CDI's prevalence, predisposing factors, and clinical outcomes in Saudi hospitalized IBD patients. : A retrospective case-control study was conducted at a tertiary medical city in Riyadh, Saudi Arabia. All Saudi adult patients with IBD, admitted over the preceding four years were identified from the hospital's database. Eligible patients were divided into those with CDI and those without CDI. Binary logistic regression was used to determine the predisposing factors for CDI among admitted IBD patients. During the study period, 95 patients were admitted with IBD. Crohn's disease (CD) was the predominant type (71.6%), whereas 28.4% of the patients were with ulcerative colitis (UC). Only 16 (16.8%) patients had positive CDI. CDI-positive patients tend to have hypertension and previous use of steroids. Patients with UC tend to have a higher risk of CDI than those with CD. Most patients recovered from the CDI (81.3%) with a median time to CDI clearance of 14 days. Three patients (18.8%) had recurrent CDI; among them, one died. The prevalence of CDI in Saudi IBD patients is similar to that reported elsewhere. UC, steroid treatment, and hypertension are risk factors for CDI in IBD patients. Recurrence of CDI in IBD patients is common and associated with a poor prognosis.

Adverse drug reactions, a guide for dentists

Adverse drug reactions (ADRs) are unintended or harmful effects due to the use of a medicine. Antibiotics and analgesics, which incidentally, are commonly prescribed by dentists, result in most of the ADRs globally. As with most healthcare professionals, dentists do not report on ADRs regularly. Therefore, the aim of the review was to explore the drugs most used in dental practice in South Africa (SA), their associated ADRs and the ADR reporting channels. The study undertook a literature review that focused on studies of adverse drug reactions specifically in dental practices. An electronic search was done on EBSCO host to source articles published from 2000 to 2022. There was a plethora of ADRs that were found to occur with the medicines that are prescribed by dentists that ranged from minor to serious. Although all medicines have a risk of ADRs, amoxicillin can result in gastrointestinal disturbances and anaphylactic reactions, while clindamycin has a risk of Clostridium difficile infection. Patients need to be alerted to the risk of a disulfiram reaction with metronidazole and alcohol. Hepatic failure can occur with paracetamol use especially in patients with underlying liver disease, an alcoholic or in an overdose. Ibuprofen, caution in patients with underlying ulcers as gastrointestinal bleeding is a risk. Local anesthetics pose a high threat of severe reactions such as tissue necrosis and direct neurotoxicity while anterograde amnesia, respiratory depression and thrombosis can occur with benzodiazepines. Dentists can prevent ADRs by having a good knowledge of their prescribed drugs, monitoring their patients and by being judicious in their prescribing habits.

Predicted Bezlotoxumab Exposure in Patients Who Have Received a Hematopoietic Stem Cell Transplant

Bezlotoxumab is approved for prevention of recurrent Clostridioides (Clostridium) difficile infection (CDI) in adults receiving antibacterial treatment for CDI who are at high risk for recurrent CDI. Previous studies have shown that although serum albumin levels are an important predictor for bezlotoxumab exposure, this has no clinically meaningful impact on efficacy. This pharmacokinetic modeling study assessed whether hematopoietic stem cell transplant (HSCT) recipients, at increased risk of CDI and exhibiting decreased albumin levels within the first month posttransplant, are at risk of clinically relevant reductions in bezlotoxumab exposure. Observed bezlotoxumab concentration-time data pooled from participants in Phase III trials MODIFY I and II (ClinicalTrials.gov identifiers NCT01241552/NCT01513239) and three Phase I studies (PN004, PN005, and PN006) were used to predict bezlotoxumab exposures in two adult post-HSCT populations: A Phase Ib study of posaconazole including allogeneic HSCT recipients (ClinicalTrials.gov identifier NCT01777763; posaconazole-HSCT population); and a Phase III study of fidaxomicin for CDI prophylaxis (ClinicalTrials.gov identifier NCT01691248; fidaxomicin-HSCT population). The bezlotoxumab PK model used the minimum albumin level for each individual in post-HSCT populations to mimic a "worst-case scenario." Predicted worst-case bezlotoxumab exposures for the posaconazole-HSCT population (N=87) were decreased by 10.8% versus bezlotoxumab exposures observed in the pooled Phase III/Phase I data set (N=1587). No further decrease was predicted for the fidaxomicin-HSCT population (N=350). Based on published population pharmacokinetic data, the predicted decrease in bezlotoxumab exposure in the post-HSCT populations is not expected to have a clinically meaningful effect on bezlotoxumab efficacy at the recommended 10 mg/kg dose. Dose modification is therefore not required in the hypoalbuminemia setting expected post-HSCT.

Interventional Antibiotic Treatment Replacing Antibiotic Prophylaxis during Allogeneic Hematopoietic Stem Cell Transplantation Is Safe and Feasible: A Single-Center Analysis

Background: Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) are at increased risk of infection-related mortality during the pre-engraftment period. Systemic antibiotic prophylaxis (SAP) is widely used during the period of neutropenia but is associated with disruption of the intestinal microbiome, an increased risk of Clostridium difficile infection (CDI) and colonization with multi-drug resistant (MDR) bacteria. Aims: We retrospectively assessed the safety and efficacy of a change in our center policy from SAP to an exclusively interventional antibiotic treatment (IAT) in adult patients undergoing allogeneic HSCT. Outcome measures were overall survival (OS) and non-relapse mortality (NRM) at 3 years, antibiotic administration, incidence of blood-stream infections (BSI) and incidence and severity of acute and chronic graft-versus-host disease (GVHD). Methods: Cefotaxime was used as standard of care prophylaxis during neutropenia after HSCT prior to January 2018. After a 12 months transition time during which both strategies were employed in parallel, SAP was replaced by an IAT strategy with meropenem being administered immediately by nursing staff in case of neutropenic fever or any other signs of infection, and subsequently deescalated to piperacillin/tazobactam (pip/taz) when appropriate. We compared 67 consecutive patients undergoing HSCT in 2017, all of whom received antibiotic prophylaxis (SAP cohort) with all patients in 2019 comprising the IAT cohort (n=68). Use of antibiotics is reported as number of daily doses per 100 care days (DDD/100CD) until discharge after HSCT. Results: Patient characteristics are summarized in table 1. Median age was 56 years, 82% of patients were grafted with peripheral blood stem cells (PBSC) for acute leukemia (74%) from a matched unrelated or related donor (MUD, 61%; MRD 17%). Patient characteristics were well balanced between the SAP and IAT cohorts, except those patients transplanted in 2019 were more likely to have an HCT-CI ≥ 3 (56% vs 36%, p=0.025) and receive reduced-intensity conditioning (62% vs 40%, p=0.025). In the SAP and IAT cohort, neutropenic fever was observed in 46% and 62% of patients (p=0.085). However, the cumulative incidence (CI) of BSI by day +100 post-HSCT was significantly higher in the IAT vs SAP cohort (40% vs 13%, p<0.001), which did not result in more patients admitted to the intensive care unit (13% vs 6%, p=ns) and did not translate into a higher CI of NRM at 3 years (10% vs 9%, p=ns). With a median follow-up of 1052 days, 3-year OS was 70% and 69% for the SAP and IAT cohort, resp. (p=ns, figure 1). CI of acute GVHD grade II-IV or chronic GVHD of any grade at 3 years was 34% (p=ns) and 45% (p=ns), resp., resulting in identical survival free of acute GVHD grade III-IV, chronic GVHD requiring systemic immunosuppressive therapy and relapse-free survival (GRFS) of 36% (p=ns) in both groups. We observed a tendency to a higher CI of severe chronic GVHD in the SAP cohort (27% vs 13%, p=0.08). There was no significant difference between the two cohorts in terms of newly detected colonization with MDR bacteria during conditioning and after HSCT (VRE 17%; ESBL 5%; 3/4 MRGN 5%; MRSA 0%) and the incidence of CDI was likewise equal in both cohorts (13%, p=ns). Compared to SAP, IAT resulted in significantly fewer days of antibiotic therapy (24 vs 18, p<0.001) and accordingly less administration of cefotaxime (12.8 vs 3.8 DDD/100CD), teicoplanin (26.2 vs 6.3 DDD/100CD), vancomycin (11.5 vs 8.3 DDD/100CD) and meropenem (23.1 vs 16.7 DDD/100CD). Solely use of pip/taz increased (14.3 vs 23.6 DDD/100CD), while the amount of imipenem remained unchanged (7.6 versus 7.8 DDD/100CD). Thus, we observed a significant 40% reduction of the median antibiotic consumption (p=0.0312) in 2019. In the multivariate analysis, only age > 60 years and a high or very high disease risk index were identified as negative prognostic factor for OS. Conclusion/Summary: Our single center experience in conducting HSCT without antibiotic prophylaxis but with strict guidelines for prompt antibiotic intervention demonstrated no disadvantage in OS and NRM, despite a higher CI of BSI. IAT resulted in considerably less consumption of cefotaxime, but also carbapenem and glycopeptide antibiotics. We conclude that the proposed procedure of IAT replacing SAP is safe and feasible. Larger patient numbers are needed to confirm a possible benefit of IAT on GVHD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

An Unusual Cause of Acidosis in a Man With Clostridium difficile Colitis

An Unusual Cause of Acidosis in a Man With Clostridium difficile Colitis

S1567 Celiac Disease Patients Have Higher Risk for Clostridium difficile Infections: A Population-Based Study

Introduction: Clostridium difficile infection (CDI) is a common gastrointestinal pathology with the incidence in the United States to 20-30 per 100 000 population. Previous studies showed association of Celiac disease and CDI, however the prevalence of CDI in patients with celiac disease has not been described in literature. Our aim is to estimate the prevalence of CDI among celiac patients, and to assess whether celiac disease is an independent risk factor for CDI. Methods: A large multi-center database (Explorys Inc., Cleveland, OH, USA) of aggregated electronic health records of 26 different healthcare systems with a total of 360 hospitals and more than 70 million patients across the United States was utilized for this study. A cohort of patients with Celiac disease was identified. Later, a second sub-cohort of those who also had CDI was identified. We excluded all the patients age < 18, patients with inflammatory bowel diseases, immunosuppressed, HIV, Roux-en-Y bypass. Statistical Package for Social Sciences (SPSS version 25, IBM Corp) was used for statistical analysis, and for all analyses, a 2-sided P-value of < 0.05 was considered statistically significant. Multivariate analysis was performed to adjust for multiple factors including age, sex, race, smoking, use of proton pump inhibitors, diagnosis of celiac disease. Results: Among the 80,884,400 individuals screened in the database there were total of 143,180 with Celiac disease (0.17%). The baseline characteristics of patients with Celiac disease are represented in Table. Celiac disease was independently associated with a higher risk of developing CDI (OR= 2.592). Other factors associated with risk of CDI included age 18-65 (OR= 2.764), White race (OR =1.880), smoking (OR= 1.540), use of proton pump inhibitors (OR= 8.468) as in the Figure. Conclusion: Celiac disease seems to be an independent risk factor for CDI. Further studies are required to investigate specifics of pathophysiology, diagnosis and treatment of CDI in patient with celiac disease.Figure 1.: Multivariable analysis for risk factors in individuals with Clostridium Difficile Infection Table 1. - Baseline Catachrestic of Study Population. Celiac disease (%)N=143,180 No celiac disease (%)N=80,741,220 Age 18-65 9,7340 (67.9) 47,893,510 (59.3) >65 39,400 (27.5) 21,266,990 (26.2) Sex Male 1,640 (1.15) 189,850 (0.24) Race Caucasian 117,430 (82.0) 42,011,260 (52.0) Comorbidities Clostridium difficile 2,050 (1.43) 231,830 (0.29) Hypertension 45,710 (31.9) 14,183,650 (17.5) Type 2 Diabetes 20,050 (13.9) 5,651,930 (6.9) Hyperlipidemia 51,170 (35.7) 11,782,380 (14.5) Smoking 19,480 (13.6) 3,874,810 (52.0) Medications PPI 54,790 (38.27) 86,37,610 (10.70)

P32 Therapeutic dilemma due to gut complications with spondyloarthritis

Introduction/BackgroundTumor necrosis factor (TNF) inhibitor therapy is one of the primary modalities of treating spondyloarthritis. However, infections secondary to biologic use is a common complication. Clostridium difficile is a gut colonizer which may become pathogenic in the presence of dysbiosis and antibiotic use. Symptomatic clostridium difficile infection(CDI) due to adalimumab(ADA) use causing lymphocytic colitis(LC) is rarely reported. We present a case of axial plus peripheral spondyloarthritis on adalimumab who developed CDI and presented a therapy related dilemma.Description/MethodWe present a case of a 52-year-old lady who was diagnosed as HLAB27 positive axial spondyloarthritis with bilateral sacroiliitis on MRI bilateral sacroiliac joint in 2016. She failed two non-steroidal antinflammatory drugs (NSAID) with high disease activity scores(BASDAI 8.6, BASFI 6.2, Spinal VAS 9). She was eventually initiated on injection adalimumab in 2017. There was clinical improvement after 6 months of initiating ADA. Repeat MRI spine and SI joint showed resolution of inflammatory changes with adalimumab. Sulfasalazine was added in the treatment protocol due to peripheral arthralgia, however she developed a drug rash to it and it was stopped. In September 2021, she developed recurrent non-bloody watery diarrhoeal episodes. Adalimumab was stopped and she tested positive for Clostridium difficile on three occasions. She received multiple courses of vancomycin, fidoxamycin and metronidazole with partial resolution of diarrhoea. Adalimumab was rechallended in January 2022 since her disease activity was worsening in the absence of NSAID and biologic use. However, it was paused again due to worsening of diarrhoea. Gastroenterology conducted a Colonoscopy and biopsy of colonic polyps which showed increased number of intraepithelial lymphocytes with no thickening of subepithelial collagen plate suggestive of lymphocytic colitis (LC). It was postulated that CDI may have been the trigger for her LC. She has been started on local corticosteroid therapy(budesonide) for her LC. At this junction, we were faced with the decision of restarting adalimumab for her which may have been the original cause of her CDI.Discussion/ResultsWe present this case in view of a dilemma regarding which problem occurred first Did immunosuppression due to adalimumab lead to CDI? Literature is not suggestive of increased risk of CDI with adalimumab, especially in a non-inflammatory bowel disease (IBD) background. Was the lymphocytic colitis triggered by the CDI or was clostridium difficile just incidentally detected on a background of LC? There is a well documented associated of LC with autoimmune conditions and use of NSAIDs along with proton pump inhibitor is another trigger for it. TNF alpha inhibitor is one of the treatment modalities of refractory LC. Would it be appropriate to restart ADA for her since she responded well despite there being a risk of recurrence of a CDI? Finally, what is the role of gut dysbiosis in the role of CDI and LC in this situation. Presently, she is planned to be treated with local steroid therapy for her LC. ADA will be rechallenged once her gut has responded to the steroid course. In the event of her gut worsening on a rechallenge, she will be given a trial of Infliximab.Key learning points/ConclusionThe case highlights the crucial point of thinking of causes of diarrhea apart from well documented conditions of ulcerative colitis/Crohn’s disease in an immunosuppressed spondyloarthritis patient. A detailed stool examination including bacterial and parasitic examination is crucial in recurrent diarrhea. The threshold for colonoscopy should be low when episodes are refractory to treatment. The case-based conference gives us an opportunity to receive feedback regarding further management approaches in this case.

Surgical Outcome in Laparoscopic Abdominal Surgical Operations with Clostridium Difficile Infection.

Introduction: Postoperative Clostridium difficile infection (CDI) has associated morbidity, but it is unknown how it impacts different operations. We sought to determine the incidence and postoperative morbidity following abdominal surgery.Method: The National Surgical Quality Improvement Program database (2015-2019) was utilized to evaluate adult (≥18 years-old) patients who developed CDI following laparoscopic abdominal operations. Univariate and multivariate analysis were performed to evaluate outcomes.Results: A total of 973338 patients were studied and the overall incidence of CDI was .3% within 30 days of operation. Colorectal surgery had the highest incidence of CDI (1601/167949,1.0%) with significantly longer mean length of stay (LOS) (8.0 days± 9.0, P < .01) compared to other surgical procedures. CDI patients also had a longer mean length of stay (6.6± 8.0 vs 2.1 ± 3.6 days, P < .01) and increased mortality (1.8% vs .2%, AOR: 4.64, CI: 3.45-5.67, P < .01) compared to patients without CDI.Conclusions: This national analysis demonstrates that CDI is a significant complication following abdominal surgery and is associated with increased LOS and mortality. Furthermore, laparoscopic colorectal surgery appears to have the greatest risk of CDI. Future research is needed to determine the exact cause in order to decrease the incidence of CDI by reconsidering the protocol of antibiotic use within the high-risk population.

Antibiotic-prescribing practices and associated outcomes after common urologic procedures in an integrated healthcare system

Background: Many urologists continue antibiotics after common urologic procedure beyond the timeframes recommended by professional guidelines. In this study, we sought to evaluate the association between postprocedural antibiotic use and patient outcomes. Methods: We identified all patients who underwent 1 of 3 urologic procedures (transurethral resection of bladder tumor [TURBT], transurethral resection of prostate [TURP], and ureteroscopy) within the Veterans’ Health Administration (VHA) between January 1, 2017, and June 30, 2021. A postprocedural antibiotic was any antibiotic potentially used for a urinary tract–related indication that was prescribed for administration after the day of the procedure. Outcomes were captured within 30 days of the procedure and included (1) return visits, defined as any emergency department or urgent care encounter or hospital readmission, and (2) Clostridium difficile infection (CDI), defined as a positive test for C. difficile and the prescription of an anti-CDI antibiotic. We used log-binomial models with risk adjustment to determine the association between postprocedural antibiotic use and outcomes. We constructed hospital-level observed-to-expected ratios for postprocedural antibiotic use, and we used these models to calculate the probability of each patient receiving postprocedural antibiotics. Results: Overall, we identified 74,629 patients; 98% were male; the mean age was 70 years (SD, 10). Among them, 50% underwent TURBT, 28% underwent TURP, and 23% underwent ureteroscopy. A postprocedural antibiotic was prescribed to 25,738 (35%) cases for a median duration of 3 days (IQR, 3–6). Return visits occurred in 13,489 patients (18%), and CDI occurred in 104 patients (0.1%). Patients exposed to postprocedural antibiotics had 16% more return visits (RR, 1.16; 95% CI, 1.13–1.20) and more than twice as much CDI (RR, 2.22; 95% CI, 1.51–3.26) than patients not exposed to postprocedural antibiotics. In log-binomial risk-adjusted analysis, the risk of return visits did not differ between the 2 groups (RR, 1.00; 95% CI, 0.97–1.04) but the risk of CDI was higher in patients who received post-procedural antibiotics (RR, 1.87; 95% CI, 1.00–3.51). Hospitals (n = 105) varied widely in their observed-to-expected ratios for prescribing postprocedural antibiotics, and the frequency of return visits was similar regardless of the frequency at which postprocedural antibiotics were prescribed (Table 1). Conclusions: Postprocedural antibiotics were prescribed beyond recommended intervals after more than one-third of common urologic procedures, with a large degree of variability across hospitals. The use of postprocedural antibiotics was not associated with fewer return visits but was associated with a nonsignificant increase in CDI risk. Efforts to reduce postprocedural antibiotics are needed.Funding: YesDisclosures: This work was funded, in part, by the Merck Investigator Studies Program. This work was also supported by a Career Development Award (DJL) from the VA Health Services Research and Development Service (CDA 16-204) and by the Iowa City VA Health Care System, Department of Pharmacy Services.

Clostridium difficile infection after ileostomy closure and anastomotic failure in rectal cancer surgery patients.

BackgroundDiverting ileostomy during resection of rectal cancer is frequently performed in patients at risk of anastomotic failure. Clostridium difficile infection (CDI) is reported to be frequent in patients who receive ileostomy closure with a questionable association to postoperative anastomosis leak. The primary aim of this study was to determine the incidence of CDI following ileostomy closure in patients who underwent rectal cancer surgery; the secondary aim was to assess the rate of postileostomy closure CDI in patients who presented with leakage at the original colorectal anastomosis site.MethodsMedical records of patients with rectal cancer who underwent ileostomy closure between January 2015 and December 2019 were retrospectively reviewed. All patients had previously received resection and anastomosis for primary rectal cancer with diverting ileostomy. Data regarding CDI incidence, preoperative status, perioperative management, and clinical outcomes were collected. CDI positivity was determined by direct real-time PCR and enzyme-linked fluorescent assays for detecting toxin A and B.Statistical analyses were computed for CDI risk factors.ResultsA total of 1270 patients were included and 208 patients were tested for CDI owing to colitis-related symptoms. The incidence of CDI was 3.6 per cent (46 patients). Multivariable analysis for CDI risk factors identified adjuvant chemotherapy (hazard ratio (HR) 2.28; P = 0.034) and colorectal anastomosis leakage prior to CDI (HR 3.75; P = 0.008). Finally, patients with CDI showed higher colorectal anastomosis leakage risk in multivariable analysis after ileostomy closure (HR 6.922; P = 0.001).ConclusionPatients with CDI presented with a significantly higher rate of colorectal anastomosis leakage prior to ileostomy closure.

Hand hygiene as the basic method of reducing Clostridium difficile infections (CDI) in a hospital environment.

Clostridium difficile spores, due to their ability to adapt to adverse conditions in a hospital environment, cause enormous difficulties associated with the effective decontamination of surfaces and equipment. Elimination of this pathogen is possible through effective implementation of the hand hygiene procedure by all hospital employees. Scientific research indicates that a properly adopted hand washing procedure reduces the risk of Clostridium difficile infection (CDI) by half. The aim of the study was to indicate the sources of nosocomial infections, mainly Clostridium difficile infection, and methods to limit them, with particular attention paid to the proper hand hygiene of the medical staff, which plays a fundamental role in the transmission of infections between hospitalized patients. Epidemiological studies indicate that about a half of Healthcare Associated Infection (HAI) is caused by microbes that contaminate the hands of medical personnel. One of the main pathogens is Clostridium difficile, which in 2018 in Poland accounted for 41.52% of all detected outbreaks originating from the hospital environment. According to data from WHO,16 million people worldwide die from Healthcare Associated Infection every year, of which approximately 17% constitutes mortality among people infected with Clostridium difficile. Non-compliance with hand hygiene among members of medical staff contributes to nosocomial infections which are a major cause of disease complications and deaths. Proper hand hygiene is a key measure for reducing this phenomenon. In every medical institution, especially in hospitals, and staff should be reminded about it and trained to perform the correct hand hygiene technique.

Analysis of Perioperative Risk Factors for Clostridium difficile Infection After a Colectomy.

IntroductionThe removal of the terminal ileum may interfere with gut-associated lymphoid tissue function, reduce bile salt reabsorption, and change intraluminal pH, which may contribute to the development of Clostridium difficile infection (CDI) after ileocolic resections. Therefore, we compared CDI incidence among patients who underwent a colectomy with or without removal of the terminal ileum.MethodsUsing the 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Targeted Colectomy database, we identified 17,962 patients who underwent a left-sided colectomy without removal of the terminal ileum and 5,929 patients who underwent an ileocolic resection involving the removal of the terminal ileum. Patients who underwent an emergency operation or had enterocolitis as the indication for surgery were excluded.ResultsPatients who underwent an ileocolic resection developed higher rates of postoperative CDI than those who underwent a left hemicolectomy (p<0.001). Multivariate logistic regression analysis demonstrated that removing the ileum was associated with a 50% higher risk of developing CDI than patients who underwent a left-sided colectomy. Additional risk factors for developing postoperative CDI were advanced age (p=0.001) and mechanical bowel preparation (p=0.001). On the other hand, factors independently associated with a lower risk of postoperative CDI were male gender (p<0.001), preoperative oral antibiotics (p<0.001), and preoperative chemotherapy use within 90 days (p<0.013).ConclusionOverall, patients who undergo operations involving the removal of the ileum are at higher risk for developing CDI. To reduce the risk among these patients, we suggest employing preoperative oral antibiotics in part of bowel preparation. Furthermore, it is critical to maintain hygienic measures, such as handwashing and disinfecting surfaces, and attentive care for these patients.