Antibiotic‐associated colitis caused by Clostridium difficile : relapse and risk factors

Abstract

Relapse is a common sequel of antibiotic‐associated colitis due to Clostridium difficile. It has been suggested that Cl. difficile may persist in the stools in spite of the resolution of symptoms after treatment and this may cause the relapse. Our study was designed to define the factors that predispose to relapse and to determine if prolonging treatment to clear Cl. difficile from the stools might prevent relapse. Of 60 consecutive patients, 36 with more severe disease required treatment. Treatment with either vancomycin or bacitracin was continued until the results of the examination of stools for cytotoxin became negative and Cl. difficile could no longer be cultured (sensitivity of culture was 10–100 organisms/mL). This was achieved in 35 patients who were then followed for one month. Symptoms reappeared in 10 (28.6%) of the treated patients while Cl. difficile reappeared in the stools of an additional seven patients (20%) without the recurrence of diarrhoea. On comparing those who relapsed with those who did not, the age (67.3 ± 5.5 years in those who relapsed compared with 51.6 ± 4.4 years; P < 0.025, x¯ ± SE) and a history of recent abdominal surgery (59% of those who relapsed compared with 17%; P < 0.05) were significantly different. Although those who relapsed had received therapy with multiple antibiotic agents more often, this was not statistically significant. Disease was not more severe in patients who relapsed, nor was it more difficult to clear the pathogen from these patients. The 24 untreated patients did not suffer symptomatic relapse. Continuation of treatment until Cl. difficile apparently is absent from the stools is expensive and does not prevent relapse. Elderly patients and those who have recently undergone abdominal sugery are more likely to suffer a relapse.

Increasing Prevalence and Severity of Clostridium difficile Colitis in Hospitalized Patients in the United States

“…Payer data revealed that many patients used Medicare insurance; this proportion increased from 66.10% in the earlier period to 67.70% in the later period. The mean±SEM Deyo comorbidity score was 1.82 ± 0.004; it increased from 1.75 ± 0.009 in the earlier period to 1.88 ± 0.007 in the middle period (January 1, 1997-December 31,2000), and then declined to 1.81±0.006 in the later period. In addition, the mean ± SEM length of stay was 14.10 ± 0.04 days; it decreased from 15.90±0.09 days in the earlier period to 13.50±0.04 days in the later period (Table 1).…”

“…Proportionately, more patients with C difficile colitis were women than men ( Table 1), although this difference decreased over time (59.80% of cases of C difficile colitis in women during the earlier period [January 1, 1993-December 31, 1996] vs 58.90% of cases in the later period [January 1, 2001-December 31, 2003]). During the 11-year study period, the mean±SEM age increased from 65.60±0.09 years in the earlier period (January 1, 1993-December 31,1996) to 67.60±0.06 years in the later period (January 1, 2001-December 31,2003). Payer data revealed that many patients used Medicare insurance; this proportion increased from 66.10% in the earlier period to 67.70% in the later period.…”

“…21 However, patients who are sicker (eg, those who are immunocompromised, those who are older, those who have low serum albumin levels, those who require an intensive care unit stay, or those who have undergone recent abdominal surgery) have an increased risk of severe C difficile colitis. 26,[30][31][32] Therefore, the increasing severity of C difficile colitis identified in our study may be because of the increasing acuity of illness of hospitalized patients in the United States. We did find an overall increase in the comorbidities of admitted patients during our study period, but even after adjusting for comorbidities, we still found an increase over time in the prevalence, case fatality, and colectomy rate for C difficile colitis.…”

Clostridium difficilein Long-Term–Care Facilities for the Elderly

“…Recurrence of symptomatic infection has been reported in up to 26% of elderly nursing home residents despite appropriate treatment. 28,30 One study also found that recurrent CDAD was more likely to occur in older adults (mean age, 67 years) than in those who were younger, 53 but in most other studies, age did not appear to be a prognostic factor for failure to respond to treatment, recurrence, or other complications. 52,[54][55][56][57]…”

Medical versus Surgical Patients with Clostridium difficile Infection: Is There Any Difference?

“…CDI recurrence was defined as return of symptoms with a repeat positive C. difficile assay within 15 to 45 days (after a 14-day course of antibiotic treatment) after the first positive result. [18][19][20] Disease severity was determined according to the classification created jointly by the Infectious Disease Society of America (IDSA) and the Society for Healthcare Epidemiology of America, with mild or moderate disease defined as leukocytosis of <15,000 3 10 3 /mL with a serum creatinine <1.5 times baseline and severe disease being that of a leukocytosis $15,000 3 10 3 /mL or a serum creatinine $1.5 times baseline. 21…”