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Risk factors and clinical outcomes for Clostridioides difficile infections in a case control study at a large cancer referral center in Mexico

  • Daniel De-la-Rosa-Martinez
    Affiliations
    Instituto Nacional de Cancerologia, Department of Infectious Diseases, Mexico City, Mexico
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  • Author Footnotes
    # Frida Rivera-Buendía current address: Oficina de Apoyo Sistemático para la Investigación Superior, Department of Clinical Research, Instituto Nacional de Cardiología, Mexico City, Mexico.
    Frida Rivera-Buendía
    Footnotes
    # Frida Rivera-Buendía current address: Oficina de Apoyo Sistemático para la Investigación Superior, Department of Clinical Research, Instituto Nacional de Cardiología, Mexico City, Mexico.
    Affiliations
    Instituto Nacional de Cancerologia, Department of Infectious Diseases, Mexico City, Mexico
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  • Patricia Cornejo-Juárez
    Affiliations
    Instituto Nacional de Cancerologia, Department of Infectious Diseases, Mexico City, Mexico
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  • Bertha García-Pineda
    Affiliations
    Instituto Nacional de Cancerologia, Department of Infectious Diseases, Mexico City, Mexico
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  • Author Footnotes
    ## Carolina Nevarez-Lujan current address: Hospital General de México “Eduardo Liceaga”, Department of Infectious Diseases, Mexico City, Mexico.
    Carolina Nevárez-Luján
    Footnotes
    ## Carolina Nevarez-Lujan current address: Hospital General de México “Eduardo Liceaga”, Department of Infectious Diseases, Mexico City, Mexico.
    Affiliations
    Instituto Nacional de Cancerologia, Department of Infectious Diseases, Mexico City, Mexico
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  • Diana Vilar-Compte
    Correspondence
    Address correspondence to Diana Vilar-Compte, MD, MSc, Department of Infectious Diseases, Instituto Nacional de Cancerología, San Fernando 22, Mexico City, México 14080.
    Affiliations
    Instituto Nacional de Cancerologia, Department of Infectious Diseases, Mexico City, Mexico
    Search for articles by this author
  • Author Footnotes
    # Frida Rivera-Buendía current address: Oficina de Apoyo Sistemático para la Investigación Superior, Department of Clinical Research, Instituto Nacional de Cardiología, Mexico City, Mexico.
    ## Carolina Nevarez-Lujan current address: Hospital General de México “Eduardo Liceaga”, Department of Infectious Diseases, Mexico City, Mexico.
Published:February 12, 2022DOI:https://doi.org/10.1016/j.ajic.2022.02.011

      Highlights

      • The incidence of Community-Onset, Healthcare Facility-Associated (CO-HCFA-CDI) cases increased from 2016 to 2018.
      • The Clostridioides difficile infection (CDI) rate was lower compared to other series of patients with cancer.
      • Cephalosporins, fluoroquinolones, and proton-pump inhibitors increased the risk of CDI acquisition.
      • Fever, abdominal pain, and ≥4 episodes of diarrhea/24h were related to CDI diagnosis.
      • Older age and male gender were associated with severe initial CDI episodes.
      • Thirty-day all-cause mortality was higher among CDI patients than controls.

      Abstract

      Introduction

      Clostridioides difficile infection (CDI) is recognized as the leading cause of nosocomial diarrhea. This study describes CDI's clinical characteristics, risk factors, and outcomes in the cancer population.

      Methods

      We conducted a case-control study on cancer patients from 2015-2018 at the Instituto Nacional de Cancerologia in Mexico. CDI case was defined as diarrhea episode and positive polymerase chain reaction (PCR) for toxigenic strains. Controls were cancer diagnosis-matched patients with diarrhea and negative PCR. Healthcare Facility-Onset (HO-CDI) and Community-Onset, Healthcare Facility-Associated (CO-HCFA-CDI) rates were calculated. For assessing associations, univariate and multivariate logistic regression analyses were conducted.

      Results

      We included 148 CDI cases and 148 controls. The CDI rate was 4.1 per 10,000 patient-days and 2.1 per 1,000 patient admissions for HO-CDI and CO-HCFA-CDI episodes, respectively. Clinical characteristics associated with CDI were fever, abdominal pain, and ≥4 episodes of diarrhea/24h. Previous use of proton pump inhibitors (P=.003), fluoroquinolones (P=.016), and cephalosporins (P=.026) increased the risk for CDI acquisition, while higher age (P=.022) and male gender (P=.015) were related to severe episodes. Thirty-day all-cause mortality was higher among CDI patients (18%) than controls (9%).

      Conclusion

      The CDI rate was lower compared to other series. The incidence of CO-HCFA-CDI episodes increased, and HO-CDI cases decreased from 2016 to 2018. Risk factors for acquisition and severe infection were similar to those reported in non-cancer populations.

      Key Words

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      References

        • Lessa FC
        • Mu Y
        • Bamberg WM
        • et al.
        Burden of Clostridium difficile Infection in the United States.
        N Engl J Med. 2015; 372: 825-834
        • Guh AY
        • Mu Y
        • Winston LG
        • et al.
        Trends in U.S. burden of Clostridioides difficile infection and outcomes.
        N Engl J Med. 2020; 382: 1320-1330
        • Zhang S
        • Palazuelos-Munoz S
        • Balsells EM
        • Nair H
        • Chit A
        • Kyaw MH.
        Cost of hospital management of Clostridium difficile infection in United States-a meta-analysis and modelling study.
        BMC Infect Dis. 2016; 16: 447
        • Dávila LP
        • Garza-González E
        • Rodríguez-Zulueta P
        • et al.
        Increasing rates of Clostridium difficile infection in Mexican hospitals.
        Braz J Infect Dis. 2017; 21: 530-534
        • Ochoa-Hein E
        • Sifuentes-Osornio J
        • Ponce de León-Garduño A
        • Torres-González P
        • Granados-García V
        • Galindo-Fraga A
        Factors associated with an outbreak of hospital-onset, healthcare facility-associated Clostridium difficile infection (HO-HCFA CDI) in a Mexican tertiary care hospital: a case-control study. Deshpande A, editor.
        PLoS One. 2018; 13e0198212
        • Gupta A
        • Tariq R
        • Frank RD
        • et al.
        Trends in the incidence and outcomes of hospitalized cancer patients with Clostridium difficile infection: a nationwide analysis.
        J Natl Compr Cancer Net. 2017; 15: 466-472
        • Delgado A
        • Reveles IA
        • Cabello FT
        • Reveles KR.
        Poorer outcomes among cancer patients diagnosed with Clostridium difficile infections in United States community hospitals.
        BMC Infect Dis. 2017; 17: 448
        • Kamboj M
        • Son C
        • Cantu S
        • et al.
        Hospital-Onset Clostridium difficile infection rates in persons with cancer or hematopoietic stem cell transplant: a C3IC network report.
        Infect Control Hosp Epidemiol. 2012; 33: 1162-1165
        • Revolinski SL
        • Munoz-Price LS.
        Clostridium difficile in Immunocompromised hosts: a review of epidemiology, risk factors, treatment, and prevention.
        Clin Infect Dis. 2019; 68: 2144-2153
        • Loo VG
        • Bourgault A-M
        • Poirier L
        • et al.
        Host and pathogen factors for Clostridium difficile infection and colonization.
        N Engl J Med. 2011; 365: 1693-1703
        • Pepin J
        • Saheb N
        • Coulombe M-A
        • et al.
        Emergence of fluoroquinolones as the predominant risk factor for clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec.
        Clin Infect Dis. 2005; 41: 1254-1260
        • Deshpande A
        • Pasupuleti V
        • Thota P
        • et al.
        Community-associated Clostridium difficile infection and antibiotics: a meta-analysis.
        J Antimicrob Chemother. 2013; 68: 1951-1961
        • Howell MD
        • Novack V
        • Grgurich P
        • et al.
        Iatrogenic gastric acid suppression and the risk of nosocomial clostridium difficile infection.
        Arch Intern Med. 2010; 170: 7
        • Dial S
        • Delaney J a.C
        • Barkun AN
        • Suissa S
        Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease.
        JAMA. 2005; 294: 2989-2995
        • Bishop KD
        • Castillo JJ.
        Risk factors associated with Clostridium difficile infection in adult oncology patients with a history of recent hospitalization for febrile neutropenia.
        Leuk Lymphoma. 2012; 53: 1617-1619
        • Gu S-L
        • Chen Y-B
        • Lv T
        • et al.
        Risk factors, outcomes and epidemiology associated with Clostridium difficile infection in patients with haematological malignancies in a tertiary care hospital in China.
        J Med Microbiol. 2015; 64: 209-216
        • Hebbard AIT
        • Slavin MA
        • Reed C
        • et al.
        Risks factors and outcomes of Clostridium difficile infection in patients with cancer: a matched case-control study.
        Support Care Cancer. 2017; 25: 1923-1930
        • Fuereder T
        • Koni D
        • Gleiss A
        • et al.
        Risk factors for Clostridium difficile infection in hemato-oncological patients: a case control study in 144 patients.
        Sci Rep. 2016; 6: 31498
        • Hebbard AIT
        • Slavin MA
        • Reed C
        • et al.
        The epidemiology of Clostridium difficile infection in patients with cancer.
        Expert Rev Anti Infect Ther. 2016; 14: 1077-1085
        • Rodríguez Garzotto A
        • Mérida García A
        • Muñoz Unceta N
        • et al.
        Risk factors associated with Clostridium difficile infection in adult oncology patients.
        Support Care Cancer. 2015; 23: 1569-1577
        • McDonald LC
        • Gerding DN
        • Johnson S
        • et al.
        Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).
        Clin Infect Dis. 2018; 66: e1-48
        • Cohen SH
        • Gerding DN
        • Johnson S
        • et al.
        Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA).
        Infect Control Hosp Epidemiol. United States;. 2010; 31: 431-455
        • Surawicz CM
        • Brandt LJ
        • Binion DG
        • et al.
        Guidelines for diagnosis, treatment, and prevention of clostridium difficile infections.
        Am J Gastroenterol. 2013; 108: 478-498
        • Finn E
        • Andersson FL
        • Madin-Warburton M
        Burden of Clostridioides difficile infection (CDI) - a systematic review of the epidemiology of primary and recurrent CDI.
        BMC Infect Dis. 2021; 21: 456
        • Chopra T
        • Chandrasekar P
        • Salimnia H
        • Heilbrun LK
        • Smith D
        • Alangaden GJ.
        Recent epidemiology of Clostridium difficile infection during hematopoietic stem cell transplantation: CDI in hematopoietic transplantation.
        Clin Transplant. 2011; 25: E82-E87
        • Lee-Tsai YL
        • Luna-Santiago R
        • Demichelis-Gómez R
        • et al.
        Determining the risk factors associated with the development of Clostridium difficile infection in patients with hematological diseases.
        Blood Res. 2019; 54: 120-124
        • Trifan A
        • Stanciu C
        • Girleanu I
        • et al.
        Proton pump inhibitors therapy and risk of Clostridium difficile infection: systematic review and meta-analysis.
        World J Gastroenterol. 2017; 23: 6500-6515
        • Lopardo G
        • Morfin-Otero R
        • Moran-Vazquez II
        • et al.
        Epidemiology of Clostridium difficile: a hospital-based descriptive study in Argentina and Mexico.
        Braz J Infect Dis. 2015; 19: 8-14
        • Morfin-Otero R
        • Garza-Gonzalez E
        • Aguirre-Diaz SA
        • et al.
        Clostridium difficile outbreak caused by NAP1/BI/027 strain and non-027 strains in a Mexican hospital.
        Braz J Infect Dis. 2016; 20: 8-13
        • Loo VG
        • Oughton M
        • Bourgault A-M
        • Kelly M
        • Dewar K
        • Monczak Y
        A predominantly clonal multi-institutional outbreak of clostridium difficile–associated diarrhea with high morbidity and mortality.
        N Engl J Med. 2005; 8
        • Arvand M
        • Vollandt D
        • Bettge-Weller G
        • Harmanus C
        • Kuijper EJ
        Clostridium difficile study group Hesse. Increased incidence of Clostridium difficile PCR ribotype 027 in Hesse, Germany, 2011 to 2013.
        Euro Surveill. 2014; 19: 20732
        • Quesada-Gomez C
        • Rodriguez C
        • Gamboa-Coronado M d.M
        • et al.
        Emergence of Clostridium difficile NAP1 in Latin America.
        J Clin Microbiol. 2010; 48: 669-670
        • McDonald LC
        • Killgore GE
        • Thompson A
        • et al.
        An epidemic, toxin gene-variant strain of Clostridium difficile.
        N Engl J Med. 2005; 353: 2433-2441
        • Camacho-Ortiz A
        • López-Barrera D
        • Hernández-García R
        • et al.
        First Report of Clostridium difficile NAP1/027 in a Mexican Hospital. Heimesaat MM, editor.
        PLoS One. 2015; 10e0122627
        • Yoon YK
        • Kim MJ
        • Sohn JW
        • et al.
        Predictors of mortality attributable to Clostridium difficile infection in patients with underlying malignancy.
        Support Care Cancer. 2014; 22: 2039-2048
        • Vargas E
        • Apewokin S
        • Madan R
        Role of the leukocyte response in normal and immunocompromised host after Clostridium difficile infection.
        Anaerobe. 2017; 45: 101-105
        • Patel UC
        • Wieczorkiewicz JT
        • Tuazon J.
        Evaluation of advanced age as a risk factor for severe Clostridium difficile infection.
        J Clini Gerontol Geriatr. 2016; 7: 12-16
        • Henrich TJ
        • Krakower D
        • Bitton A
        • Yokoe DS.
        Clinical risk factors for severe Clostridium difficile –associated disease.
        Emerg Infect Dis. 2009; 15: 415-422
        • Lessa FC
        • Mu Y
        • Winston LG
        • et al.
        Determinants of clostridium difficile infection incidence across diverse United States geographic locations.
        Open Forum Infect Dis. 2014; 1 (ofu048)
        • Fekety R
        • McFarland LV
        • Surawicz CM
        • Greenberg RN
        • Elmer GW
        • Mulligan ME.
        Recurrent Clostridium difficile Diarrhea: characteristics of and risk factors for patients enrolled in a prospective, randomized, double-blinded trial.
        Clin Infect Dis. 1997; 24: 324-333
        • Klein SL
        • Flanagan KL.
        Sex differences in immune responses.
        Nat Rev Immunol. 2016; 16: 626-638