Study Finds 32 Predictors of C Diff Infection Recurrence

Nearly 1 out of 5 patients with Clostridium difficile infections (CDI) progress to have 1 or more recurring infections, often within a month of treatment, but now a new study has identified predictors for recurrence.

“Following the first recurrence, the risk of an additional episode of CDI increases to between 45% and 65%,” note the study’s authors. “Recurrent CDI is challenging to treat and causes significant morbidity, mortality, and reductions in quality of life. Identifying those at highest risk for recurrence could allow for targeted initial CDI management and may improve patient outcomes.”

For the research, published in the American Journal of Health-System Pharmacy, investigators conducted a matched case-control study among patients in the veteran population treated for their first CDI episode in Veterans Affairs facilities across the United States from May 1, 2010 to December 30, 2014. Study investigators defined first recurrence as a subsequent CDI episode at least 14 days after the positive stool test date and within 30 days of the end of treatment of the initial CDI occurrence, noting that previous research has found that the risk for recurrence is highest 10 days after treatment completion.

Of the 49,064 patients with an initial CDI episode, the investigators identified 974 cases that experienced a first recurrence as well as 3896 controls matched on year, facility, and severity that did not experience first recurrence. Among cases and controls, the study team observed severe CDI in 36.8% of patients and mild CDI in 39.9%.

In an interview with Contagion^® study co-author Haley J. Appaneal, PharmD, discussed some of the 32 predictors of recurring CDI found by the research team. “Among the most important risk factors we identified were use of certain drugs including antibiotics, proton pump inhibitors, and immunosuppressants, and conditions such as biliary tract disease, certain cancers, and ulcerative colitis,” said Appaneal. “Clinicians should recognize that patients with a first CDI episode who also are being treated with antibiotics, proton pump inhibitors, or immunosuppressants or who have certain underlying comorbid conditions are at risk for CDI recurrence.”

Interestingly, the study team also found that use of probiotics such as Lactobacillus, Bifidobacteria, or Saccharomyces boulardii — which have been thought to restore the colonic microbiota in the setting of recurrent CDI – prior to and after CDI treatment – was actually associated with an increased risk for CDI recurrence. The study authors note a possible explanation for this unexpected link is that that some patients at an increased risk for recurrence were prescribed probiotics by their physicians.

The new findings are in line with prior research linking antibiotic use and CDI. Appaneal explains that the study’s findings can be used by clinicians to optimize treatment of initial CDI to lower the risk of recurrence. “Our study might change the way health care providers treat their patients with CDI by motivating them to more carefully review the medication regimens of their patients and to stop any antibiotics or proton pump inhibitors (PPIs) that are not necessary,” noted Appaneal.

“Antibiotics and PPIs should only be taken when they are needed and as directed by their doctor. When antibiotics and PPIs are not needed, they are not helpful and may increase risk for CDI recurrence. To avoid recurrence, patients should let their doctor know of all prescription and OTC drugs they are taking, talk to their doctor before starting any new drugs, and only take drugs as directed by their doctor.”