C Diff, COVID-19 Coinfection Risk Greatest in Older Women


Those with certain comorbidities, including peptic ulcer disease and renal failure, were at additional risk of developing C diff infection.

A retrospective analysis that examined outcomes in patients with COVID-19 and C diff coinfection revealed an independent association with increased mortality, with women and those with pre-existing conditions especially at risk of developing the gut infection.

Investigators led by Xheni Deda, MD, of the University of Missouri School of Medicine, used the National Inpatient Sample database to identify adults hospitalized with a primary diagnosis of COVID-19 in 2020 and those with a secondary diagnosis of C diff. Ultimately, 1,045,125 COVID-19 hospitalizations were identified, of which 4920 had a coinfection of C diff.

Overall, patients coinfected were more likely to be older white females (mean age, 69.9; 54.1% female; 60% white) and had nearly double the length of hospital stay (14.1 vs. 7.42 days; P < .001) compared with those without C diff coinfection. In addition, this group saw higher total hospital costs ($42,336 vs. $18,974; P < .001), and higher inpatient mortality, with a mortality rate of 21.6% in the C diff and COVID-19 group compared with 11% in the COVID-19 group without C diff (P < .001). Age also plays a significant role in mortality, with previous research confirming this study’s findings of increased risk with older age, with a 6-fold greater mortality rate seen in those age 80 years and older.

These findings also reinforce prior research demonstrating an increased risk of C diff infection by 3% for each additional day of hospitalization.

Beyond female gender, comorbidities independently associated with C diff infection in patients diagnosed with COVID-19 included peptic ulcer disease, renal failure, weight loss, diabetes mellitus with complications, congestive heart failure, cardiac arrhythmias, liver disease, and non-metastatic solid organ tumors, with peptic ulcer disease and renal failure associated with the highest odds of developing C diff infection (OR 2.3; 95% CI: 1.1 - 4.7; OR 1.9; 95% CI: 1.6 - 2.4, respectively). The authors noted that proton pump inhibitor use is likely a contributor to the increased risk in this population.

“These findings emphasize the importance of considering CDI as a potential complication in COVID-19 patients, particularly in the presence of identified risk factors,” the authors wrote. Further, it emphasizes the importance of prevention strategies to help curb the strain on health care resources.

C diff testing, diagnosis, and treatment remains a challenge in today’s health care sphere. There are ongoing conversations to improve metrics around C diff, including attributing infections to hospital-onset, which has measurable implications for Centers for Medicare & Medicaid Services reimbursement. Recent research Kalvin Yu, MD, and colleagues sought to improve criteria for defining hospital-onset C diff, suggesting that it be based on the decision to treat as well as laboratory identification more than 3 days after admission, and a risk-adjusted model that assesses prevalence of community onset CDI, length of hospital stay, rate of ICU admissions, hospital characteristics such as bed-size and urban or rural setting, as well as testing prevalence and and testing intensity.

Deda X, Elfert K, Gandhi M, et al. clostridioides difficile infection in covid-19 hospitalized patients: a nationwide analysis. Gastroenterol Res. 2023;16(4):234-239. doi:10.14740/gr1639
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