Recurrent Clostridium Difficile Infection in Out-patients
BackgroundClostridium difficile infection (CDI) recurs in 20–30% of patients.
Aim To describe the predictors of recurrence in out-patients with CDI.
Methods Out-patient cases of CDI in Olmsted County, MN residents diagnosed between 28 June 2007 and 25 June 2010 were identified. Recurrent CDI was defined as recurrence of diarrhoea with a positive C. difficile PCR test from 15 to 56 days after the initial diagnosis with interim resolution of symptoms. Patients who had two positive tests within 14 days were excluded. Cox proportional hazard models were used to assess the association of clinical variables with time to recurrence of CDI.
Results The cohort included 520 out-patients; 104 had recurrent CDI (cumulative incidence of 17.5% by 30 days). Univariate analysis identified increasing age and antibiotic use to be associated with recurrent CDI. Severe CDI, peripheral leucocyte count and change in serum creatinine >1.5-fold were not. In a multiple variable model, concomitant antibiotic use was associated with risk of recurrent CDI (HR = 5.4, 95% CI 1.6–17.5, P = 0.005), while age (HR per 10 year increase = 1.1, 95% CI 0.9–1.3, P = 0.22); peripheral leucocyte count >15 × 10/L (HR = 1.0, 95% CI 0.5–2.1, P = 0.92); and change in serum creatinine greater than 1.5-fold (HR = 0.8, 95% CI 0.4–1.5, P = 0.44) were not.
Conclusions Antibiotic use was independently associated with a dramatic risk of recurrent Clostridium difficile infection in an out-patient cohort. It is important to avoid unnecessary systemic antibiotics in patients with Clostridium difficile infection, and patients with ongoing antibiotic use should be monitored closely for recurrent infection.
Clostridium difficile infection (CDI) causes significant morbidity and mortality, and the incidence of CDI in the hospital setting has increased significantly over the past 15 years. Recurrent infection occurs in about 20% of patients with CDI. The risk of recurrence increases with multiple episodes, and there is an approximate 65% risk of additional recurrence in those with two or more episodes of CDI.
Recurrent CDI is defined by the Infectious Disease Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) as the presence of diarrhoea and a positive Clostridium difficile stool assay within 2–8 weeks from the initial episode. Early recurrences generally occur within the first 2–3 weeks after the initial infection, however late infections can occur up to 8 weeks.
Predicting the risk of recurrence of CDI is important for several reasons, including the necessity to closely monitor those identified to be at higher risk. Management of recurrent CDI, especially multiple recurrences, poses a clinical dilemma as there is a lack of strong evidence for a specific treatment strategy. Longer courses of metronidazole and vancomycin, pulse-dosed or tapering regimens of vancomycin, probiotics, rifaximin, fidaxomicin, immunotherapy and faecal microbial transplantation have been used to treat recurrent CDI.
Studies have assessed predictors of recurrent CDI, including gender, older age, illness severity, ongoing antibiotic use, serum concentrations of immunoglobulin G (IgG) against toxin A, vancomycin-resistant enterococcus (VRE) colonisation, anaemia, use of proton pump inhibitors (PPI), renal insufficiency, underlying immunosuppression, history of diabetes, elevated leucocyte count, presence of a nasogastric tube, nursing home residence, history of recurrent CDI, presence of cramps on initial presentation and diverticulosis. However, the existing data on predictors of recurrent CDI come from in-patient cohorts, with relatively little known about risk factors for recurrent infection in out-patients. Furthermore, some of these variables such as anti-toxin A IgG are not routinely available. Testing for VRE may not be routinely performed in out-patients. In this study, we aimed to identify predictors of the risk of recurrent CDI in out-patients.
Abstract and Introduction
Abstract
BackgroundClostridium difficile infection (CDI) recurs in 20–30% of patients.
Aim To describe the predictors of recurrence in out-patients with CDI.
Methods Out-patient cases of CDI in Olmsted County, MN residents diagnosed between 28 June 2007 and 25 June 2010 were identified. Recurrent CDI was defined as recurrence of diarrhoea with a positive C. difficile PCR test from 15 to 56 days after the initial diagnosis with interim resolution of symptoms. Patients who had two positive tests within 14 days were excluded. Cox proportional hazard models were used to assess the association of clinical variables with time to recurrence of CDI.
Results The cohort included 520 out-patients; 104 had recurrent CDI (cumulative incidence of 17.5% by 30 days). Univariate analysis identified increasing age and antibiotic use to be associated with recurrent CDI. Severe CDI, peripheral leucocyte count and change in serum creatinine >1.5-fold were not. In a multiple variable model, concomitant antibiotic use was associated with risk of recurrent CDI (HR = 5.4, 95% CI 1.6–17.5, P = 0.005), while age (HR per 10 year increase = 1.1, 95% CI 0.9–1.3, P = 0.22); peripheral leucocyte count >15 × 10/L (HR = 1.0, 95% CI 0.5–2.1, P = 0.92); and change in serum creatinine greater than 1.5-fold (HR = 0.8, 95% CI 0.4–1.5, P = 0.44) were not.
Conclusions Antibiotic use was independently associated with a dramatic risk of recurrent Clostridium difficile infection in an out-patient cohort. It is important to avoid unnecessary systemic antibiotics in patients with Clostridium difficile infection, and patients with ongoing antibiotic use should be monitored closely for recurrent infection.
Introduction
Clostridium difficile infection (CDI) causes significant morbidity and mortality, and the incidence of CDI in the hospital setting has increased significantly over the past 15 years. Recurrent infection occurs in about 20% of patients with CDI. The risk of recurrence increases with multiple episodes, and there is an approximate 65% risk of additional recurrence in those with two or more episodes of CDI.
Recurrent CDI is defined by the Infectious Disease Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) as the presence of diarrhoea and a positive Clostridium difficile stool assay within 2–8 weeks from the initial episode. Early recurrences generally occur within the first 2–3 weeks after the initial infection, however late infections can occur up to 8 weeks.
Predicting the risk of recurrence of CDI is important for several reasons, including the necessity to closely monitor those identified to be at higher risk. Management of recurrent CDI, especially multiple recurrences, poses a clinical dilemma as there is a lack of strong evidence for a specific treatment strategy. Longer courses of metronidazole and vancomycin, pulse-dosed or tapering regimens of vancomycin, probiotics, rifaximin, fidaxomicin, immunotherapy and faecal microbial transplantation have been used to treat recurrent CDI.
Studies have assessed predictors of recurrent CDI, including gender, older age, illness severity, ongoing antibiotic use, serum concentrations of immunoglobulin G (IgG) against toxin A, vancomycin-resistant enterococcus (VRE) colonisation, anaemia, use of proton pump inhibitors (PPI), renal insufficiency, underlying immunosuppression, history of diabetes, elevated leucocyte count, presence of a nasogastric tube, nursing home residence, history of recurrent CDI, presence of cramps on initial presentation and diverticulosis. However, the existing data on predictors of recurrent CDI come from in-patient cohorts, with relatively little known about risk factors for recurrent infection in out-patients. Furthermore, some of these variables such as anti-toxin A IgG are not routinely available. Testing for VRE may not be routinely performed in out-patients. In this study, we aimed to identify predictors of the risk of recurrent CDI in out-patients.
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