Clostridium difficile–Associated Diarrhea in the Oncology Patient

Clostridium difficile is the most common cause of nosocomial diarrhea, resulting in significant morbidity and mortality in hospitalized patients. Oncology patients are particularly at risk of this infection secondary to frequent exposure to known risk factors. In a population in which diarrhea is a common adverse effect of chemotherapeutic regimens, diagnosis can be challenging secondary to current limitations in testing to differentiate between colonization and active infection. Although several currently available antimicrobial therapies achieve resolution of symptoms in this population, further research is needed to determine which agent least affects the host intestinal microbiota, especially in times of neutropenia and mucosal barrier injury. The purpose of this article is to review the current literature on the epidemiology, pathogenesis, and management of C difficile–associated diarrhea in the oncology population.

Download Full-text

Incidence of Mucosal Barrier Injury Bloodstream Infections Reported to the National Healthcare Safety Network

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.871 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s293-s294

Author(s):

Prachi Patel ◽

Margaret A. Dudeck ◽

Shelley Magill ◽

Nora Chea ◽

Nicola Thompson ◽

...

Keyword(s):

Infection Type ◽

National Level ◽

Bloodstream Infections ◽

Mucosal Barrier ◽

Risk Models ◽

Oncology Patient ◽

Model Calculations ◽

Specific Patient ◽

Mucosal Barrier Injury ◽

The Impact

Background: The NHSN collects data on mucosal barrier injury, laboratory-confirmed, bloodstream infections (MBI-LCBIs) as part of bloodstream infection (BSI) surveillance. Specialty care areas (SCAs), which include oncology patient care locations, tend to report the most MBI-LCBI events compared to other location types. During the update of the NSHN aggregate data and risk models in 2015, MBI-LCBI events were excluded from central-line–associated BSI (CLABSI) model calculations; separate models were generated for MBI-LCBIs, resulting in MBI-specific standardized infection ratios (SIRs). This is the first analysis to describe risk-adjusted incidence of MBI-LCBIs at the national level. Methods: Data were analyzed for MBI-LCBIs attributed to oncology locations conducting BSI surveillance from January 2015 through December 2018. We generated annual national MBI-LCBI SIRs using risk models developed from 2015 data and compared the annual SIRs to the baseline (2015) using a mid-P exact test. To account for the impact of an expansion in the MBI-LCBI organism list in 2017 from 489 organisms (32 genera) to 1,003 organisms (89 genera), we removed the MBI-LCBI events that met the newly added MBI organisms and generated additional MBI SIRs for 2017 and 2018. Results: The annual SIRs remained above 1 since 2015, indicating a greater number of MBI-LCBIs identified than were predicted based on the 2015 national data (Fig. 1). Each year’s SIR was significantly different than the national baseline, and the highest SIR was observed in 2017 (SIR, 1.377). In 2017, 12% of MBI events were attributed to an organism that was added to the MBI organism list, and in 2018 it was 10%. After removal of MBIs attributed to the expanded organisms, the 2017 and 2018 SIRs remained higher than those of previous years (1.241 and 1.232, respectively). Conclusions: The distinction of MBI-LCBIs from all other CLABSIs provides an opportunity to assess the burden of this infection type within specific patient populations. Since 2015, the increase of these events in the oncology population highlights the need for greater attention on prevention strategies pertinent to MBI-LCBI in this vulnerable population.Funding: NoneDisclosures: None

Download Full-text

Comparison of Clostridium Difficile Associated Diarrhea Detection by Enzyme Linked Immunosorbent Assay (EIA) and Polymerase Chain Reaction (PCR) in Autologous Hematopoietic Stem Cell Transplant (AHSCT) Recipients

Blood ◽

10.1182/blood.v118.21.4739.4739 ◽

2011 ◽

Vol 118 (21) ◽

pp. 4739-4739

Author(s):

Kenneth Utz ◽

Christopher Frei ◽

Bonita Neumon ◽

Brenda L. Frye ◽

Deanna Schneider ◽

...

Keyword(s):

Polymerase Chain Reaction ◽

Stem Cell ◽

Clostridium Difficile ◽

Enzyme Linked Immunosorbent Assay ◽

Repeated Testing ◽

Chain Reaction ◽

Hematopoietic Stem ◽

Common Cause ◽

Polymerase Chain ◽

Clostridium Difficile Associated Diarrhea

Abstract Abstract 4739 Background: Diarrhea is a frequent complication of autologous hematopoietic stem cell transplantation and is a common cause of morbidity. Clostridium difficile associated diarrhea (CDAD) is the most common cause of nosocomial infections. Detection of CDAD is widely performed using enzyme linked immunosorbent assay (EIA) to C. difficile toxins A and B because of its technical ease of use and rapid results. The sensitivity of EIA is 60%, but the sensitivity increases with repeated testing. Recently, detection of CDAD by Polymerase Chain Reaction (PCR) methodology has resulted in rapid detection of amplified C. difficile toxin (CDT) B chromosomal material and has been shown to be more sensitive than EIA in patients suspected of CDAD; however, no comparison of the two methodologies has been performed in recipients of an autologous hematopoietic AHSCT. Methods: This retrospective analysis of AHSCT recipients at our institution evaluates the incidence of CDAD when using either EIA or PCR. CDAD was assessed at the onset of diarrhea in both cohorts. The time period of interest was from 7 days prior to transplantation to 30 days posttransplanation. In the EIA cohort, three consecutive liquid stools were tested for the presence of CDT A and B by EIA. In the PCR cohort, only one liquid stool was sent for sampling. Our institution adopted PCR methodology on 1 February 2010. Demographic and clinical information were collected to assess CDAD risk. Successful treatment of CDAD was defined as resolution of diarrhea within seven days. Previously published data from our institution have shown the incidence of CDAD to be 15% when using EIA methodology. Nominal data were analyzed by Fisher's Exact Test and continuous data were analyzed by Student's T-Test. Results: A total of 159 patients were screened; and 16 patients were excluded because they did not have a CDAD test performed. Seventy-three were included in the EIA cohort and 69 were included in the PCR cohort. Clinical characteristics were similar between the groups. Known risk factors for CDAD including days in the hospital, days of neutropenia, and days of prophylactic and intravenous antibiotics used were similar between the cohorts. The incidence of a positive CDAD test was higher in the EIA cohort compared to the PCR cohort (18% vs. 7% [p = 0.049]). The duration of diarrhea was longer in the EIA cohort as compared to the PCR cohort (7.3 days vs. 5.5 days [0.016]). Of the three consecutive EIA tests sent, the first was positive only 30% (4/13) of the time. Metronidazole was the first-line agent used in all cases. Response to therapy was poor in both the EIA and PCR cohorts with rates of 30% and 20%, respectively. No fatalities occurred in either group as a result of CDAD. Conclusion: The incidence of diarrhea was significantly shorter in the PCR cohort as compared to the EIA cohort. The duration of diarrhea was significantly shorter in the PCR group as compared to the EIA cohort. It is possible that repeated testing for CDAD by EIA decreases the specificity of the test or that the EIA is detecting a non-toxigenic C. difficile enterotoxin. Because our patient population has additional causes of diarrhea including mucosal irritation caused by chemotherapy, additional studies are needed to discern the discrepancies between both methodologies. Disclosures: No relevant conflicts of interest to declare.

Download Full-text