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Identifying High-Risk Recurrent Clostridioides Difficile Patients for Bezlotoxumab

The greatest risk factors for recurrent Clostridioides difficile infection (CDI) were age of at least 65 years, severe primary CDI, and use of non-CDI antibiotics. Patients with these risk factors should be prioritized for bezlotoxumab therapy.

Clostridioides difficile infection (CDI) is the most common hospital-acquired infection in the US. C diff infections are associated with a high risk of mortality, but among the survivors, approximately 27% are readmitted to the hospital within a month with recurrent CDI.

One study, presented virtually at the 2022 Critical Care Congress, sought to review and improve the process of identifying patients at high risk of recurrent CDI. They aimed to implement a strategy to discern which patients should qualify for bezlotoxumab, a monoclonal antibody that decreases the risk of recurrent CDI.

The investigators performed a retrospective chart review of adult patients tested for CDI from August 2019-March 2020. Included participants were diagnosed with recurrent CDI (rCDI) within 90 days of a primary CDI (pCDI). Clinical pCDI cure had to be achieved prior to hospital readmission for participants to be included in the study. The adult participants were hospitalized for pCDI and rCDI, and received standard-of-care antibiotics for CDI. Patients who initially received bezlotoxumab were excluded from the study.

The study included 31 CDI patients who met inclusion criteria. Included participants ranged from 50-95 years old, with an average age of 71. The cohort was 45.2% male. During pCDI, 41.9% of the participants were admitted to the intensive care unit (ICU). Twenty-nine patients were readmitted to the hospital, including some who were readmitted more than once.

High-risk factors for rCDI were age of at least 65 years, immunosuppressing disease or medication, severe CDI, use of non-CDI antibiotics, chronic use of proton pump inhibitors (PPIs), and contracting highly virulent C diff strains NAP1/B1/027. Most patients in the cohort had 2 or more high-risk factors for rCDI. The highest risk factors were age above 65 years and severe CDI, which 64.5% of the cohort had. Use of non-CDI antibiotics was also a high risk, seen in 61.2% of study patients.

In presenting the research, lead author Cassidy J. Treanor, PharmD, noted that bezlotoxumab is the only human monoclonal antibody approved to decrease CDI recurrence in high-risk patients. During the study period, 16 patients were identified for bezlotoxumab treatment due to rCDI. Of these, 69% were identified for bezlotoxumab after 2 or more cases of CDI, and 63% were immunocompromised.

Treanor said that the current system excels at identifying CDI patients for bezlotoxumab, but may be optimized by considering the high-risk factors the study identified, such as advanced age, severe CDI, and use of non-CDI antibiotics. Improving the identification of bezlotoxumab recipients can prevent the high burden of healthcare costs, morbidity, and mortality associated with Clostridioides difficile infection and recurrent CDI.