Background: Polymerase chain reaction (PCR) is a sensitive test for diagnosing Clostridioides difficile infection (CDI) and could remain positive following resolution of CDI. The kinetics of PCR positivity following antibiotics for CDI is unknown. We studied this and whether it predicted CDI recurrence. Methods: Adults with CDI from October 2009 to May 2017 were included. Serial stool samples within 60 days of treatment were collected. Recurrent CDI was defined as diarrhea after interim symptom resolution with positive stool PCR within 56 or 90 days of treatment completion. Contingency table analysis was used to assess the risk of recurrence. Results: Fifty patients were included [median age: 51 (range = 20–86) years, 66% women]. Treatment given was metronidazole, 50% (25); vancomycin, 44% (22); both, 4% (2); and fidaxomicin, 2% (1). Median duration of treatment for all 50 patients was 14 (range = 8–60) days. The median duration of treatment in patients who got prolonged therapy (>14 days) ( n = 10) was 47 (range = 18–60) days. Median time to negative PCR was 9 (95% CI, 7–14) days from treatment initiation, which did not differ by antibiotics given ( p = 0.5). A positive PCR during or after treatment was associated with a higher risk of recurrence at 56 days ( p = 0.02) and at 90 days ( p = 0.009). Conclusion: The median time to negative PCR in CDI was 9 days from treatment initiation. The PCR positivity during or after treatment may be useful for recurrence prediction; larger studies are needed to validate these results.
Background: The incidence of Clostridioides difficile infection (CDI) is increasing in the general population. Data on the epidemiology of CDI in peripartum women – a highly vulnerable patient population – is scarce. The objective of this study was to report the incidence of CDI in peripartum women. Methods: A single-center retrospective cohort study was conducted in peripartum women from 1997 to 2017. Peripartum CDI was defined as definite CDI (watery diarrhea for >24 h with positive stool assay) during pregnancy, or within 6 weeks postpartum. Incidence was reported per 100,000 pregnancies and time trends in incidence were analyzed using Poisson regression. Analyses were done separately for time trends before and after 2007, when CDI testing strategy changed to polymerase chain reaction. Results: From 1997 to 2017, 80 patients with peripartum CDI (47 during pregnancy, 33 postpartum) out of 125,683 pregnancies (0.064%) were identified. Incidence of CDI increased 3.4 fold (95% confidence interval 1.5–7.4, p = 0.005) over the 21 year period. Time trends were evident after ( p = 0.054), but not before 2007 ( p = 0.97). Conclusion: Incidence of CDI in peripartum women increased over the 21 year study period. The rise in incidence is concerning, and calls for heightened surveillance for CDI in this highly vulnerable population.
INTRODUCTION: Testing strategies for Clostridioides difficile infection (CDI) remain a clinical conundrum with stool polymerase chain reaction (PCR) being highly sensitive; this high sensitivity may mean that PCR would remain positive for several weeks after CDI resolution. We studied the kinetics of PCR testing positivity in CDI, and whether a positive test during or after treatment predicts recurrence. METHODS: Adults with watery diarrhea and positive C. difficile PCR from 10/2009 to 5/2017 were included. Treatment was given per standard of care. Five serial stool samples collected within 60 days after treatment initiation and additionally clinically indicated samples were included. Recurrent CDI was defined as typical CDI symptoms after interim symptom resolution with positive stool PCR within 56 days of treatment. A positive stool test in the absence of symptoms was considered colonization and treatment was not offered. Descriptive statistics and Fisher's test were used, as appropriate. Kaplan-Meier survival curves for time to first negative PCR from treatment initiation, and log-rank test to compare treatments [metronidazole (MET) vs vancomycin (VAN)] were used. P < 0.05 was considered statistically significant. RESULTS: Fifty patients, median age 51 (range 20–86) years, 66% female, were included. Initial treatment was MET in 50% (25), VAN in 44% (22), both MET and VAN in 4% (2) and fidaxomicin in 2% (1). Median treatment duration was 14 (range 8–60) days. Overall, 82% (41) patients submitted ≥3 samples at variable times. Median time to first negative PCR was 9 days (95% CI, 7–14 days) after treatment initiation (Figure 1). This was similar in MET and VAN treated patients (P = 0.5; Figure 2). CDI recurred in 28% (14) of patients. Overall, 13 patients (33%) had ≥1 positive PCR(s) during and 45% (19) had ≥1 positive PCR(s) after treatment. Patients with positive vs negative PCR(s) during treatment trended towards a higher risk of recurrence [OR 3.9 (95% CI, 0.9–16.1), P = 0.054]. Patients with positive PCR(s) after treatment completion also had a non-significant trend towards a higher risk of recurrence [OR 2.8 (95% CI, 0.7–11.5), P = 0.15]. CONCLUSION: Median time to first negative PCR in CDI was 9 days from treatment initiation. Positive PCR during or after treatment did not predict recurrence, though the positive odds ratio indicates the need for a larger study. Patients with CDI should not routinely undergo repeat testing to predict recurrence.
INTRODUCTION: Currently, surgery is the primary treatment option for refractory, severe-complicated Clostridioides difficile infection (CDI) in the inpatient setting. There are limited series reporting the efficacy of Fecal Microbiota Transplantation (FMT) to treat such cases as an alternative to surgery or in patients who are not surgical candidates. We aimed to assess the response rate and prognosis of these patients after inpatient FMT. METHODS: We conducted a retrospective chart review of patients with CDI (watery diarrhea with positive stool assay) admitted in the ICU, and who received FMT from January 2013 to July 2016. Potential cases were identified by diagnosis codes and eligibility was confirmed through manual chart review. Severe-complicated CDI was defined as CDI with any of the following: ICU admission, hypotension, shock, sepsis, megacolon, colectomy or death due to CDI. CDI was termed refractory in the absence of clinical response to antibiotics after 5 days. Recurrence was defined as typical CDI symptoms and positive stool assay within 56 days of treatment with interim symptom resolution. The primary outcome was resolution of CDI (clinical cure with no recurrence). Secondary outcomes included risk of recurrent CDI and mortality. Microsoft Excel was used for descriptive statistical analysis. RESULTS: Of 273 patients screened, 6 cases met inclusion criteria. Five patients received FMT via colonoscopy, one via retention enema. The mean age at time of FMT was 72 (range, 54-88) years, 4 (66%) patients were female. All had severe-complicated CDI, 3 had concomitant diverticulosis and none had inflammatory bowel disease (IBD). The median follow-up after FMT was 8.5 (range, 1-18) months. Three patients received non-CDI antibiotics within 6 months post-FMT, 3 received acid suppression therapy (Table 1). FMT was performed after a median of 3 (range, 1-5) episodes of CDI with a median of 4.5 previous courses of antibiotics (range 2-6 courses) (Table 1). Four of the six patients (66%) had resolution of CDI, 2 patients had recurrence. One patient died due to sepsis secondary to CDI; 3 died due to unrelated causes. CONCLUSION: In this small retrospective study, inpatient FMT was effective for treating refractory severe-complicated CDI. There was one CDI-related mortality by the end of follow up. FMT may be an alternative therapy in patients with severe-complicated CDI.
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