Clostridium difficile–associated Diarrhea in Heart Transplant Recipients: Is Hypogammaglobulinemia the Answer?

Muñóz, Patricia; Giannella, Maddalena; Alcalá, Luís; Sarmiento, E.; Yáñez, Javier; Palomo, Jesús; Catalán, Pilar; Carbone, J.; Bouza, Emilio

doi:10.1016/j.healun.2007.07.010

Cited by 84 publications

(60 citation statements)

References 41 publications

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“…In one study, there was a fi vefold increased risk of CDI in heart transplant recipients. Th ese patients had decreased immunoglobulins and immunoglobulin therapy reduced the risk of CDI and RCDI recurrence ( 126 ). For this group of patients, IVIG may be benefi cial, but more studies are needed before this can be stated defi nitively.…”

Section: Treatment Of ≥ 3 CDI Recurrencesmentioning

confidence: 99%

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Surawicz

Brandt

Binion

et al. 2013

American Journal of Gastroenterology

1,450

1,389

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Clostridium diffi cile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratifi ed depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mildto-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classifi cation of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI. Am J Gastroenterol 2013; 108:478-498; doi: 10.1038/ajg.2013 12. In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman's pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves. (Conditional recommendation, low-quality evidence)13. The use of anti-peristaltic agents to control diarrhea from confi rmed or suspected CDI should be limited or avoided, as they may obscure symptoms and precipitate complicated disease. Use of anti-peristaltic agents in the setting of CDI must always be accompanied by medical therapy for CDI. (Strong recommendation, low-quality evidence) Management of severe and complicated CDI14. Supportive care should be delivered to all patients and includes intravenous fl uid resuscitation, electrolyte replacement, and pharmacological venous thromboembolism prophylaxis. Furthermore, in the absence of ileus or signifi cant abdominal distention, oral or enteral feeding should be continued. 17. Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and / or signifi cant abdominal distention. (Strong recommendation, low-quality evidence)18. Surgical consult should be obtained in all patients with complicated CDI. Surgical therapy should be considered in patients with any one of the following attributed to CDI: hypotension requiring vasopressor therapy; clinical signs of sepsis and organ dysfunction (renal and pulmonary); mental status changes; white blood cell count ≥ 50,000 cells / μ l, lactate ≥ 5 mmol / l; or failure to improve on medical therapy after 5 days. (Strong recommendation, moderate-quality evidence) Management of recurrent CDI (RCDI)19. The fi rst recurrence of CDI can be treated ...

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Section: Treatment Of ≥ 3 CDI Recurrencesmentioning

confidence: 99%

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Surawicz

Brandt

Binion

et al. 2013

American Journal of Gastroenterology

1,450

1,389

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“…Avoidance of acid-blocking medication may also be helpful; however, patients require these agents during the most vulnerable time period to prevent stress/steroid-induced ulcers as high-dose steroids are part of most immunosuppressive protocols [32]. Munoz et al [6] found that hypogammaglubulinemia was a risk factor for acquisition of CDAC in heart transplant patients; for abdominal organ recipients such as presented in our study, such data are not available. Evaluating IgG levels against toxin A may be useful in identifying solid organ recipients at risk for recurrent CDAC, as this has been shown also by Hu et al [33] and Kyne et al [34] in other populations.…”

Section: Discussionmentioning

confidence: 79%

“…Moreover, the course of the disease seems to be more severe in this patient population [1,4,6,10]. This high risk to develop CDAC is based on the excessive overall risk for infectious complications due to multiple factors, including end-stage organ failure, major surgical intervention, and immunosuppressive therapy, which all cause disturbances in the colonic colonization pattern [12].…”

Section: Introductionmentioning

confidence: 98%

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Solid organ recipients are at increased risk for recurrent Clostridium difficile colitis

et al. 2014

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Background Solid organ transplant (SOT) recipients carry a high risk of developing Clostridium difficileassociated colitis (CDAC) and an increased risk for recurrence.Patients and methods Between December 1996 and September 2007, a total of 227 patients with CDAC were identified when querying our institutional surgical infection database. This included 169 nontransplant patients and 58 SOT recipients, including 1 cardiac, 19 renal, 2 pancreas, 5 renal/pancreas, and 31 liver recipients.Results Overall, we recorded 556 infectious episodes at any site in the 227 patients analyzed who eventually developed CDAC (2.4 episodes/patient); the total number of CDAC episodes was 255: 204 patients had a single episode and 23 patients had multiple episodes of CDAC.There were 19 patients with two episodes, 3 with three episodes, and 1 with four episodes. Of the 23 patients with recurrent CDAC, 11 (48 %) were SOT recipients. A total of 19 % of SOT recipients had recurrent CDAC as compared with only 7 % for nontransplant patients (p = 0.0197). Time to first CDAC recurrence was a median of 58 (range, 17-1372) days for SOT recipients and a median of 30 (range, 6-108) days for nontransplant patients (p = 0.047).Conclusions SOT recipients at our institution were found to be a high-risk group for CDAC and had an almost threefold risk for recurrent disease. Double-drug coverage, extended application of metronidazole, and profound reduction in the level of immunosuppression may help to cope with this emerging problem.

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“…Una respuesta humoral enérgica frente a toxina de C. difficile tras la infección reduce la probabilidad de enfermedad sintomática. La hipogammaglobulinemia, comúnmente asociada a trasplante de hígado, pulmón o corazón, puede resultar en una respuesta inmune deficiente y aumentar cinco veces la incidencia de ICD 36 . La supresión de ácido gástrico es otro factor de riesgo frecuentemente encontrado en receptores de trasplante de órgano sólido.…”

Section: Poblaciones Especialesunclassified

Abordaje multidisciplinario de la infección por Clostridium difficile

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et al. 2013

Rev. chil. infectol.

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Clostridium difficile–associated Diarrhea in Heart Transplant Recipients: Is Hypogammaglobulinemia the Answer?

Cited by 84 publications

References 41 publications

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Solid organ recipients are at increased risk for recurrent Clostridium difficile colitis

Abordaje multidisciplinario de la infección por Clostridium difficile

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