Breakthrough Clostridium difficile Infection in Cirrhotic Patients Receiving Rifaximin

Abstract

A high percentage of CDI cases were detected in cirrhotic patients receiving rifaximin, mostly owing to selection of rifaximin-resistant C. difficile strains. Clinicians should be aware of the risk of CDI in cirrhotic patients, even in those receiving rifaximin.

Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spaish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR)

“…Early recognition of an episode of CDI is a critical step to optimize the treatment of CD and to control the transmission to other patients, and must be based in three mainstays: a correct suspicion of the illness by clinicians, an accurate and rapid laboratory diagnosis of CDI, and a rapid and effective transmission of information of these results to the attending physician, infection prevention officer, and nursing staff [20,52]. The Centers for Disease Control and Prevention (CDC) recommends to work with microbiology laboratories to ensure rapid reporting of test results for CDI, including weekends and holidays, and to ensure that there is a process for providing results to the patient care area so that isolation precautions can be initiated promptly (Center for Diseases Control and Prevention, Guidelines for preventing transmission of MDROs, 2006) [135].…”

“…Their use in the treatment of recurrences might be overshadowed by the efficacy of the currently available strategies described above. Moreover, there are reports of resistance development to rifaximin [52,173] and fusidic acid [169], which further discounts the use of these antibiotics as treatment options for CDI in any episode.…”

“…Delayed diagnosis can increase the time of patient exposition to inappropriate drugs as antiperistaltic or narcotics that can complicate CDI [148]. Similarly, fast information of a negative result favors the withdrawal of antimicrobials in patients with empiric treatment for CDI [52].…”

“…A similar observational study showed that nearly 20% of patients successfully treated for CDI had detectable spores in stool specimens at the time of the resolution of the diarrhea and it increased to 56% one to four weeks later [141]. The lack of correlation demonstrated in these studies between clearance of colonic CD and resolution of CDI has led to international guidelines to recommend not to use culture or toxin detection to follow-up the evolution of patients with CDI [20,52]. In order to reduce false positives, some experts suggest that microbiological laboratories reject stool samples from patients treated for CDI with a microbiological diagnosis in the previous seven days [19], as well as from asymptomatic patients (unless suspicion of ileum or toxic megacolon) [21].…”

“…Another study by Naggie et al, showed that 40% of the patients with CA-CDI had not received antimicrobials prior to diagnosis [51]. In a recent study published by Spanish authors, the use of rifaximin in cirrhotic patients was associated with breakthrough CDI [52]. This evidence supports that common risk factors for CDI may not be present in all patients, therefore each probable case has to be evaluated in an individualized manner and in the presence of a diarrheic episode all patients should be suspected of CDI until proven otherwise.…”