What risk factors predict which patients will develop multiple C. difficile infection (CDI) recurrences?

Bottom line: Risk factors such as age > 65, chronic hemodialysis, recent hospitalization, and nitrofurantoin use may help predict which patients will develop multiple recurrences of CDI. 

Surveillance was performed for recurrent C difficile infections (CDI) by the Centers for Disease Control and Prevention Emerging Infections Program, including results from 35 counties in 10 states.  All labs reported initially positive CDI tests (molecular or toxin assay) between 1/2018-8/2019 for people ages 18 years or older in whom no prior positives were reported.  Recurrent CDI was defined as a positive test 14 days or more following previous positive; multiple recurrent CDI (mrCDI) defined as second or subsequent recurrence with 180 days of initial positive.  18,828 patients were identified to have initial CDI; 81.6% experienced no recurrence; 13.7% had one recurrence, 4.7% with mrCDI (the majority with 2 recurrences).  Initial factors associated with mrCDI included:  age > 65 years, patients with healthcare or long-term facility onset, toxin positive disease (vs toxin negative or NAAT positive only), underlying conditions such as chronic kidney disease, diverticular disease, and malignancy), health care exposure, antibiotic use, immune suppressants, proton pump inhibitors.  The final multivariate analysis included age > 65, chronic hemodialysis, hospitalization and nitrofurantoin use in the preceding 12 weeks (thought to reflect cumulative antibiotic exposure due to urinary tract infection), with the presence of 2 or more of these risk factors resulting in a 10.2% attack rate of mrCDI.   Authors suggest using these predictors could help with patient selection for clinical trials of therapies to prevent mrCDI, but might they also help us determine which patients might benefit from the current therapies available for recurrent infection? 

Guh A, et al.  Characteristics of patients with initial Clostridioides difficile infection (CDI) that are associated with multiple CDI recurrences.  OFID.  March 6, 2024.  https://doi.org/10.1093/ofid/ofae127.

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