Clostridium difficile-associated diarrhea in radiooncology: an underestimated problem for the feasibility of the radiooncological treatment?

Abstract

Background and PurposeOver the last years an increasing incidence of Clostridium difficile-associated diarrhea (CDAD) has been reported. Especially haematology-oncology patients are at risk of developing CDAD.The aim of this analysis is to determine the incidence of CDAD in radiooncological patients and to find out what relevance CDAD has for the feasibility of the radiooncological treatment, as well as to detect and describe risk factors.Patients and MethodsIn a retrospective analysis from 2006 to 2010 34 hospitalized radiooncological patients could be identified having CDAD. The risk factors of these patients were registered, the incidence was calculated and the influence on the feasibility of the radiooncological therapy was evaluated. Induced arrangements for prophylaxis of CDAD were identified and have been correlated with the incidence.ResultsThe incidence of CDAD in our collective is 1,6%. Most of the patients suffering from a CDAD were treated for carcinoma in the head and neck area. Common risk factors were antibiotics, proton pump inhibitors, cytostatic agents and tube feeding.Beside a high rate of electrolyte imbalance and hypoproteinemia a decrease of general condition was frequent. 12/34 patients had a prolonged hospitalization, in 14/34 patients radiotherapy had to be interrupted due to CDAD. In 21 of 34 patients a concomitant chemotherapy was planned. 4/21 patients could receive all of the planned cycles and only 2/21 patients could receive all of the planned cycles in time.4/34 patients died due to CDAD. In 4/34 patients an initially curative treatment concept has to be changed to a palliative concept.With intensified arrangements for prophylaxis the incidence of CDAD decreased from 4,0% in 2007 to 0,4% in 2010.ConclusionThe effect of CDAD on the feasibility of the radiotherapy and a concomitant chemotherapy is remarkable. The morbidity of patients is severe with a high lethality.Reducing of risk factors, an intense screening and the use of probiotics as prophylaxis can reduce the incidence of CDAD.

Probiotics in Clostridium difficile infection: reviewing the need for a multistrain probiotic

“…Mortality/fatality rates as high as 26% have been reported in old and very old patients, and patients with underlying disease like progressive solid tumours. Especially haematology-oncology patients, having systemic diseases and receiving high dose chemotherapy, are at risk for CDI (Hautmann et al, 2011). Both the recurrence and overgrowth after initial dysbiosis can be partly explained by spore forming ability, specific adhesions in the colon and hypervirulent strains via additional production of a binary toxin.…”

“…The cost per case ranges from approx. 2,500 USD (total cost estimate 3.5 billion) to 4,000 USD in the UK (Hickson, 2011), with health care system costs between 5,000 (USA) and 8,000 (EU) USD per primary episode and almost 14,000 USD for a case of recurrent CDI (Hautmann et al, 2011) with a total burden worldwide in the tens of billions. All available data show that CDI is much more difficult to prevent and cure than ordinary diarrhoea.…”

“…Causes for microbiota-damage are shown at level 2 in Figure 1. Risk factors for microbiota damage are for example age, proton pump inhibitors (PPI), tube feeding and parenteral nutrition (Hautmann et al, 2011). After initial disturbance of the resident microbiota other factors can exacerbate the condition by causing an unwanted bacterial overgrowth (Figure 1: 3) resulting in a mild (osmotic) diarrhoea that is usually self limiting (in over 75% of cases).…”

“…The severity of CDI ranges from mild, usually self-limiting, diarrhoea to fulminant colitis, toxic megacolon and death. C difficile colonises and can be isolated from 0-5% of healthy adults (Hautmann et al, 2011;Hell et al, 2012;Moudgal and Sobel 2012;Parkes et al, 2009). However, this can increase to 39% in hospitalised patients (Hickson, 2011;McFarland, 2011) depending on treatment and local conditions, with individuals over the age of 65 being prime targets and age itself being a predisposing factor (referred to as 'inflammaging' and 'immunosenescence'; Islam et al, 2012).…”

Pseudomembranous colitis within radiotherapy field following concurrent chemoradiation therapy: a case report

“…Hautmann et al noted that radio-oncological patients were also patients at risk of C. difficile infection and that the incidence was 1.6%, especially for head and neck cancer patients 8. Prendergast et al reported that irradiation-associated reductions in normal beef surface flora influenced survival of nonpathogenic Escherichia coli and pathogenic E. coli , suggesting that irradiation may affect the chemical or physical composition of flora 9.…”