Changing Epidemiology of Clostridium difficile–Associated Disease during Stem Cell Transplantation

Abstract

The incidence and severity of Clostridium difficile-associated disease (CDAD) within the general population has risen dramatically over the past decade, yet little data are available from hematopoietic stem cell transplantation (HSCT) centers. In the present study, we performed a chart review of 822 consecutive autologous and allogeneic HCST recipients treated at Northwestern Memorial Hospital between 2004 and 2008 to determine the incidence of CDAD at our institution. Variables including age, sex, diagnosis, chemotherapy regimen, transplantation type, microbial colonization, coinfections, diet, antibiotic use, neutropenic fever, comorbid conditions, time to engraftment, growth factor administration, and occurrence of graft-versus-host disease were assessed as potential risk factors for the development of CDAD. Eighty-five CDAD cases (10.3%) were identified. Bivariate analysis revealed a significant association between CDAD and neutropenic fever, administration of a neutropenic diet, ciprofloxacin and aztreonam use and duration of therapy, vancomycin and aztreonam use and duration of therapy, receipt of an allogeneic transplantation, bacterial coinfection, and vancomycin-resistant Entereococcus faecium (VRE) colonization. Cox regression analysis identified the following as factors associated with the development of CDAD: age >60 years, allogeneic transplantation, and prior VRE colonization. Allogeneic recipients with CDAD experienced increased higher rates of grades II to IV gastrointestinal graft-versus-host disease and nonrelapse mortality. A risk stratification model was developed to identify HSCT recipients at different levels of risk. With an incidence >10%, CDAD is a significant infectious complication of stem cell transplantation.

Acute graft-versus-host disease of the gut: considerations for the gastroenterologist

“…The incidence of C. difficile infection among patients who receive allogeneic HSCT ranges from 12 to 27% and is associated with increased mortality 17,126,127 . Predisposing factors to C. difficile infection include age >60 years, allogeneic HSCT, chemotherapy before conditioning therapy, severe acute GVHD, use of broad-spectrum antimicrobials and prior vancomycin-resistant enterococci colonization 126 . Clinically, C. difficile infection can be indistinguishable from acute GVHD 36,128 .…”

Risk factors for recurrent Clostridium difficile infection in allogeneic hematopoietic cell transplant recipients

“…Allogeneic hematopoietic stem cell transplantation (HSCT) confers increased risk for CDI because of prolonged hospital stay, immunosuppression, the need to use broad-spectrum antibiotics and a complex interplay of chemo-preparative regimen and GvHD-induced gut mucosal damage. The incidence of CDI following autologous and allogeneic HSCT ranges from 5 to 20% [1][2][3][4][5][6][7][8] and recurrence rate has been~20%; 1 consistent with the general population. There are numerous studies describing the epidemiology and risk factors (RFs) of recurrent CDI in the general population, namely receipt of antibiotics, age 460 years, length of hospital stay and concomitant receipt of antacid medications.…”

Clostridium Difficile Colonization in Hematopoietic Stem Cell Transplant Recipients: A Prospective Study of the Epidemiology and Outcomes Involving Toxigenic and Nontoxigenic Strains

“…is an important cause of infectious diarrhea in HSCT patients, with rates of 10% -24%% [1][2][3][4] , and a 1-year incidence of 9.2% 5 . Furthermore, about 20% of the general hospitalized patients 6 and HSCT patients 5 will develop recurrence of CDI despite therapy.…”