Clostridioides difficile infection in liver cirrhosis patients: A population-based study in United States

Abstract

BACKGROUND Clostridioides (formerly Clostridium ) difficile infection (CDI) is an increasingly frequent cause of morbidity and mortality in hospitalized patients. Multiple risk factors are documented in the literature that includes, but are not limited to, antibiotics use, advanced age, and gastric acid suppression. Several epidemiological studies have reported an increased incidence of CDI in advanced liver disease patients. Some have also demonstrated a higher prevalence of nosocomial infections in cirrhotic patients. AIM To use a large nationwide database, we sought to determine CDI’s risk among liver cirrhosis patients in the United States. METHODS We queried a commercial database (Explorys Inc TM , Cleveland, OH, United States), and obtained an aggregate of electronic health record data from 26 major integrated United States healthcare systems comprising 360 hospitals in the United States from 2018 to 2021. Diagnoses were organized into the Systematized Nomenclature of Medicine Clinical Terms (SNOMED–CT) hierarchy. Statistical analysis for the multivariable model was performed using Statistical Package for Social Sciences (SPSS version 25, IBM Corp TM ). For all analyses, a two-sided P value of < 0.05 was considered statistically significant. RESULTS There were a total of 19387760 patients in the database who were above 20 years of age between the years 2018-2021. Of those, 133400 were diagnosed with liver cirrhosis. The prevalence of CDI amongst the liver cirrhosis population was 134.93 per 100.000 vs 19.06 per 100.000 in non-cirrhotic patients ( P < 0.0001). The multivariate analysis model uncovered that cirrhotic patients were more likely to develop CDI (OR: 1.857; 95%CI: 1.665-2.113, P < 0.0001) compared to those without any prior history of liver cirrhosis. CONCLUSION In this large database study, we uncovered that cirrhotic patients have a significantly higher CDI prevalence than those without cirrhosis. Liver cirrhosis may be an independent risk factor for CDI. Further prospective studies are needed to clarify this possible risk association that may lead to the implementation of screening methods in this high-risk population.

Clostridioides difficile Infection in Liver Cirrhosis: A Concise Review

“…Firstly, studies have shown females to be more prone to CDI [ 50 ]. This was confirmed in a couple of studies on cirrhosis patients [ 22 , 30 , 32 , 38 , 47 ]. Experimental and human studies have demonstrated differences in the gut microbiome concerning gender, and such effects are mediated by sex hormone levels [ 51 , 52 ].…”

“…Several studies have reported the prevalence of CDI in patients with cirrhosis using large nationwide databases. In a study conducted in an extensive commercial database in the US, the prevalence of CDI in cirrhosis was 134.93 per 100,000 of 133,400 patients diagnosed with cirrhosis between 2018–2021 [ 30 ]. Nationwide Readmissions Database (NRD) in the US revealed that the prevalence of CDI in patients with cirrhosis was 2.8% from 2011 to 2014, with higher inpatient mortality compared with cellulitis and urinary tract infections (UTI) (17.6% vs. 7.6%, 11.8%), respectively, and the presence of sepsis and organ failure was also most common in CDI [ 31 ].…”

“…Age >65 years, multiple hospitalizations, inpatient stays >20 days, hypoproteinemia, Clostridioides difficile colonization (CDC), HE, antibiotic, and proton pump inhibitors (PPIs) use were found to be associated with the development of CDI in a study conducted to identify risk factors for CDI in patients with cirrhosis [ 45 ]. Furthermore, many studies have also reported risk factors for CDI development [ 22 , 23 , 30 , 32 , 35 , 37 , 39 , 46 – 49 ] although heterogeneity exists between studies. The risk factors concluded from these studies are largely in line with the previous research and can be broadly classified into several categories, namely medications (PPIs, antibiotics, etc.…”

COVID-19 and Clostridioides difficile Coinfection Outcomes among Hospitalized Patients in the United States: An Insight from National Inpatient Database

“…Moreover, CLD is also associated with changes in the gut microbiome and bile acid synthesis, both of which have been shown to increase CDI [ 23 ]. Keeping the above mechanisms in mind, multiple studies have shown that CDI and COVID-19 are individually associated with higher morbidity and mortality in patients with CLD [ 21 , 24 , 25 , 26 ]. Therefore, it was no surprise that that our study collectively found CDI and COVID-19 to have a positive association with CLD.…”

A Systematic Literature Review on Risk Factors for and Timing of Clostridioides difficile Infection in the United States

“…Twenty-six articles included a risk estimate for sex (Fig. 2); a significantly higher risk of CDI in women compared with men was reported in 12 studies [28,43,[47][48][49][50][51][52][53][54][55]. This ranged from an aOR of 1.02 (95% CI 1.00-1.04; p value not presented) in a mixed study population in a large database study [34] to an aOR of 6.3 (95% CI 1.7-24.0; p \ 0.01) in patients with urinary tract infections (UTIs) [50].…”