Predictors of Mortality Among a National Cohort of Veterans With Recurrent Clostridium difficile Infection

Abstract Background Though recurrent Clostridium difficile infection (CDI) is common and poses a major clinical concern, data are lacking regarding mortality among patients who survive their initial CDI and have subsequent recurrences. Risk factors for mortality in patients with recurrent CDI are largely unknown. Methods Veterans Affairs patients with a first CDI (stool sample with positive C. difficile toxin(s) and ≥2 days CDI treatment) were included (2010–2014). Subsequent recurrences were defined as additional CDI episodes ≥14 days after the stool test date and within 30 days of the end of treatment. A matched (1:4) case–control analysis was conducted using multivariable conditional logistic regression to identify predictors of all-cause mortality within 30 days of the first recurrence. Results Crude 30-day all-cause mortality rates were 10.6% for the initial CDI episode, 8.3% for the first recurrence, 4.2% for the second recurrence, and 5.9% for the third recurrence. Among 110 cases and 440 controls, 6 predictors of mortality were identified: use of proton pump inhibitors (PPIs; odds ratio [OR], 3.86; 95% confidence interval [CI], 2.14–6.96), any antibiotic (OR, 3.33; 95% CI, 1.79–6.17), respiratory failure (OR, 8.26; 95% CI, 1.71–39.92), congitive dysfunction (OR, 2.41; 95% CI, 1.02–5.72), nutrition deficiency (OR, 2.91; 95% CI, 1.37–6.21), and age (OR, 1.04; 95% CI, 1.01–1.07). Conclusions In our national cohort of Veterans, crude mortality decreased by 44% from the initial episode to the third recurrence. Treatment with antibiotics, use of PPIs, and underlying comorbidities were important predictors of mortality in recurrent CDI. Our study assists health care providers in identifying patients at high risk of death after CDI recurrence.

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What Is the Role for Metronidazole in the Treatment of Clostridium difficile Infection? Results From a National Cohort Study of Veterans With Initial Mild Disease

Clinical Infectious Diseases ◽

10.1093/cid/ciy1077 ◽

2018 ◽

Vol 69 (8) ◽

pp. 1288-1295 ◽

Cited By ~ 1

Author(s):

Haley J Appaneal ◽

Aisling R Caffrey ◽

Kerry L LaPlante

Keyword(s):

Clostridium Difficile ◽

Clinical Outcomes ◽

Clostridium Difficile Infection ◽

Proportional Hazards ◽

Therapeutic Option ◽

Cox Proportional Hazards ◽

First Episode ◽

Mild Disease ◽

All Cause Mortality ◽

National Cohort

Abstract Background Metronidazole may still be an appropriate therapeutic option for mild Clostridium difficile infection (CDI) in select patients, but data are limited to guide clinicians in identifying these patients. Methods Our 2-stage study included a national cohort of Veterans with a first episode of mild CDI (2010–2014). First, among those treated with metronidazole, we identified predictors of success, defined as absence of all-cause mortality or recurrence 30 days posttreatment, using multivariable unconditional logistic regression. Second, among a subgroup of patients with characteristics predictive of success identified in the first stage, we compared clinical outcomes among those treated with metronidazole compared with vancomycin, using Cox proportional hazards models for time to 30-day all-cause mortality, CDI recurrence, and failure. Results Among 3656 patients treated with metronidazole, we identified 3282 patients with success and 374 patients without success (failure). Younger age was the only independent predictor of success. Age ≤65 years was associated with an odds of success 1.63 times higher (95% confidence interval [CI], 1.29–2.06) than age >65 years. Among 115 propensity score–matched pairs ≤65 years of age, no significant differences were observed between metronidazole and vancomycin (reference) for all-cause mortality (hazard ratio [HR], 0.29 [95% CI, .06–1.38]), CDI recurrence (HR, 0.62 [95% CI, .26–1.49]), or failure (HR, 0.50 [95% CI, .23–1.07]). Conclusions Among patients ≤65 years of age with initial mild CDI, clinical outcomes were similar with metronidazole and vancomycin. These data suggest that metronidazole may be considered for the treatment of initial mild CDI among patients 65 years of age or younger.

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A Propensity-Matched Analysis Between Standard Versus Tapered Oral Vancomycin Courses for the Management of Recurrent Clostridium difficile Infection

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx235 ◽

2017 ◽

Vol 4 (4) ◽

Cited By ~ 6

Author(s):

Chris A Gentry ◽

Stephanie E Giancola ◽

Sharanjeet Thind ◽

George Kurdgelashvili ◽

Grant H Skrepnek ◽

...

Keyword(s):

Clostridium Difficile ◽

Propensity Score ◽

Clostridium Difficile Infection ◽

Statistical Significance ◽

Administrative Database ◽

Secondary Outcome ◽

Health Administration ◽

Oral Vancomycin ◽

Recurrent Clostridium Difficile Infection ◽

All Cause Mortality

Abstract Background This study was conducted to compare clinical outcomes of oral vancomycin courses without taper versus oral vancomycin courses with taper for treatment of recurrent Clostridium difficile infection (CDI). Methods This investigation was a multicenter, retrospective, propensity score-matched analysis study using a Veterans Health Administration national clinical administrative database. Adult patients who were treated for recurrent CDI from any Veterans Affairs Medical Center between June 1, 2011 and October 31, 2016 were included if they were treated with oral vancomycin with or without a tapering regimen. The 2 groups were matched by next-nearest approach from a propensity score formula derived from independent variables associated with the selection of a taper regimen. Results Propensity score matching resulted in 2 well-matched groups consisting of 226 episodes of patients treated with a vancomycin taper regimen and 678 episodes treated by vancomycin regimen without taper. No difference was found for the primary outcome of 180-day recurrence (59 of 226 [26.1%] for taper regimens versus 161 of 678 [23.8%], P = .48). A secondary outcome of 90-day all-cause mortality met statistical significance, favoring a taper regimen (5.31% vs 9.29%, P = .049); however, secondary outcomes of 90-day recurrence and 180-day all-cause mortality were not different. Conclusions Vancomycin taper regimens did not provide benefit over vancomycin regimens without taper in preventing additional CDI recurrence in patients with first or second recurrent episodes in this propensity score-matched analysis.

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Self-Administered Home Series Fecal “Minitransplants” for Recurrent Clostridium difficile Infection on a Rectal Remnant

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld.2014.1121.244.clo ◽

2015 ◽

Vol 24 (4) ◽

pp. 531-533 ◽

Cited By ~ 1

Author(s):

Daniel Popa ◽

Mihaela Laszlo ◽

Lidia Ciobanu ◽

Elena Ucenic ◽

Manuela Mihalache ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Clostridium Difficile ◽

Clostridium Difficile Infection ◽

Toxic Megacolon ◽

Fecal Microbiota ◽

Recurrent Infections ◽

Resonance Imaging ◽

Vaginal Infection ◽

Fecal Microbiota Transplant ◽

Recurrent Clostridium Difficile Infection

A fecal microbiota transplant has proved to be an extremely effective method for patients with recurrent infections with Clostridium difficile. We present the case of a 65-year-old female patient with multiple Clostridium difficile infection (CDI) relapses on the rectal remnant, post-colectomy for a CDI-related toxic megacolon. The patient also evidenced associated symptomatic Clostridium difficile vaginal infection. She was successfully treated with serial fecal “minitransplants” (self-administered at home) and metronidazole ovules.Abbreviations: GI: gastrointestinal; MRI: magnetic resonance imaging; CDI: Clostridium difficile infection; FMT: fecal microbiota transplant.

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