Clostridium Difficile Infection in Patients Undergoing Hematopoietic Cell Transplantation. Results from the Transplantation Group at the Catholic University Hospital in Santiago, Chile

Abstract

Aldrich (2), neuroblastoma (2) and 1 osteopetrosis and 1 medulloblastoma. Norovirus was detected by RNA RT-PCR test of stool performed by Focus Diagnostics, Cypress, Ca. The dose of Nitazoxanide was 100 mg po BID for ages 1 to 4 years, 200 mg po BID for age 4 to 11 years, and 500 mg po BID for greater than 11 years. 1 pt, 33 months post allo HSCT with normal immune studies was not treated as symptoms resolved prior to test result. All other pts clinically responded with improvements in diarrhea, nausea, and abdominal pain in 2-4 days (median 2 days). 3 pts were pre-HSCT on chemo/immunotherapy and 11 were 17 days to 34 months after HSCT. All the treated pts were on immune suppression or chemotherapy. 9 allo HSCT pts were on immunosuppression and 5 of these had GVHD at onset of symptoms. Immune suppression included tacrolimus/solumedrol (3), cellcept/solumedrol (2) plus infliximab (1), tacrolimus (1), cyclosporine (1), tacrolimus/cellcept (1). 3 pts were receiving immunotherapy (1), or chemotherapy for solid tumors (2) prior to planned HSCT. 1 pt was 10 months post auto HSCT. Clearance of stool virus was variable. 2/3 pts treated prior to HSCT became negative on stool study within 5-14 days of treatment (1 unknown duration). Among pts treated after HSCT 4/9 had persistent viral shedding, 2 received drug until death (1 adenovirus, 1 CHF) both were treated greater than 2 months, 3 with GVHD still shed virus after 6 months of treatment, and 4 are off therapy and remain negative for norovirus RNA. 1 auto HSCT pt stopped viral shedding 2 months post starting Nitazoxanide. 2 HSCT pts with clinical resolution but persistent viral shedding stopped treatment and had clinical symptoms return. These pts responded to restarting therapy within 2 days but continue to shed virus. UGI endoscopy/colonoscopy were performed in 5 pts at the time of infection, all showed inflammation/edema but no GVHD was seen on histology. Peripheral blood CD4 counts among those with persistent viral shedding ranged from <50-445/ul and for those that cleared virus 143-1222/ul. Nitazoxanide is effective therapy for norovirus gastroenteritis in immune compromised patients. Therapy needs to be continued until stool RNA studies become negative.

Clostridium difficile infection is a frequent but well-controlled event after hematopoietic cell transplantation

“…The association observed between CDI and longer time to neutrophil engraftment in allogeneic HSCT observed in the study by Pilcante et al needs to be interpreted with caution 2 . One previous study identified the use of umbilical cord blood grafts as a risk factor for CDI, likely as a result of their slower engraftment 7 .…”

“…While earlier literature suggested that CDI in HSCT recipients was more severe and was associated with increased non-relapse mortality, 8 recent retrospective analyses suggest that the majority of cases of CDI are mild to moderate and respond well to antibiotic therapy 5, 9. The outcomes reported by Pilcante et al confirm that most patients experience mild diarrheal illness that responds to a single course of antibiotics 2 . Moreover, transplant outcomes and overall survival do not appear to be affected by the incidence of CDI.…”

“…The manuscript by Pilcante et al 2 is the first report of the incidence, risk factors and outcomes of CDI in patients undergoing HSCT in an academic medical center in Chile.…”