PHILADELPHIA – Every recurrence of Clostridium difficile was associated with a hospital admission in 1 in 4 cases and a complication in 1 in 15 cases, according to a retrospective Canadian cohort study.
“We do have therapeutic options targeted specifically at recurrence, namely fecal transplant, fidaxomicin, and monoclonal antibodies,” study author Dr. Caroline Sheitoyan-Pesant said at Infectious Diseases Week 2014. “But the problem with these approaches is they are either laborious, costly, or unavailable, which is why we felt the need to clarify the burden of multiple recurrences in order to use those options more wisely in the future.”
Dr. Sheitoyan-Pesant and her colleagues at the University of Sherbrooke used a positive cytotoxin and/or ICD-9 CM/ICD-10 code to identified 1,527 episodes of C. difficile infection (CDI) among 1,442 adults living in 1998-2013 in the Sherbrooke area of Quebec, Canada.
Recurrence was defined as the reappearance of diarrhea leading to treatment between 14 to 60 days following the previous episode, with or without microbiologic or endoscopic supportive evidence.
Initial CDI was community acquired in 45% of cases, and 63% of patients were aged at least 65 years.
Among 1,418 patients who did not die within 14 days of diagnosis, 25% (354) had a first recurrence, Dr Sheitoyan-Pesant said.
Subsequent recurrence rates were 38.3% (128 of 334) for the second recurrence, 29% (35 of 121) for the third, and 27.3% (9 of 33) for the fourth, with numbers quite small for the fifth (62.5%; 5 of 8), and sixth 25% (1 of 4) recurrences.
“Recurrence rates are probably more stable over time than what we used to think before and probably between 25% and 38%,” she said.
When examined by year of diagnosis, the risk of having a first recurrence was 12% during 1998-2002. After the emergence of the North American pulsed-field gel electrophoresis type 1 (NAP1) strain, however, first recurrence rates jumped to 32% in 2003-2005, 20% in 2006-2009, and 31% in 2010-2013.
The NAP1 strain has been shown to be a predictor of severe disease, severe outcome, and death in CDI (Clin. Infect. Dis. 2014;58:1394-400).
The initial CDI episode was severe in 47% of the 1,527 episodes, driven mostly by elevated white blood cell counts. The severity rate went down with each recurrence, which was not the case for complicated episodes, as those rates were stable over time, Dr. Sheitoyan-Pesant said.
The 30-day mortality rate was also stable over time, at 11% for the initial CDI episode and 7%-8% for recurrences.
The study was supported by Cubist as part of an investigator-initiated research study. Dr. Sheitoyan-Pesant reported having no financial disclosures.