Clostridium Difficile Colonization in Hematopoietic Stem Cell Transplant Recipients: A Prospective Study of the Epidemiology and Outcomes Involving Toxigenic and Nontoxigenic Strains

Abstract

Clostridium difficile is a leading cause of infectious diarrhea in hematopoietic stem cell transplant (HSCT) recipients. Asymptomatic colonization of the gastrointestinal tract occurs before development of C. difficile infection (CDI). This prospective study examines the rates, risk factors, and outcomes of colonization with toxigenic and nontoxigenic strains of C. difficile in HSCT patients. This 18-month study was conducted in the HSCT unit at the Karmanos Cancer Center and Wayne State University in Detroit. Stool samples from the patients who consented for the study were taken at admission and weekly until discharge. Anaerobic culture for C. difficile and identification of toxigenic strains by PCR were performed on the stool samples. Demographic information and clinical and laboratory data were collected. Of the 150 patients included in the study, 29% were colonized with C. difficile at admission; 12% with a toxigenic strain and 17% with a nontoxigenic strain. Over a 90-day follow-up, 12 of 44 (26%) patients colonized with any C. difficile strain at admission developed CDI compared with 13 of 106 (12%) of patients not colonized (odds ratio [OR], 2.70; 95% confidence interval [95% CI], 1.11 to 6.48; P = .025). Eleven of 18 (61%) patients colonized with the toxigenic strain and 1 of 26 (4%) of those colonized with nontoxigenic strain developed CDI (OR, 39.30; 95% CI, 4.30 to 359.0; P < .001) at a median of 12 days. On univariate and multivariate analyses, none of the traditional factors associated with high risk for C. difficile colonization or CDI were found to be significant. Recurrent CDI occurred in 28% of cases. Asymptomatic colonization with C. difficile at admission was high in our HSCT population. Colonization with toxigenic C. difficile was predictive of CDI, whereas colonization with a nontoxigenic C. difficile appeared protective. These findings may have implications for infection control strategies and for novel approaches for the prevention and preemptive treatment of CDI in the HSCT patient population.

Peri‐transplant clostridium difficile infections in patients undergoing allogeneic hematopoietic progenitor cell transplant

“…A previous study found that prior colonization with toxigenic strains of Clostridium difficile strongly predicted for the development of CDI following allogeneic HPC transplant [6]. We found a history of CDI to be a strong predictive value for the development of PT-CDI.…”

“…A study found that gastrointestinal colonization with toxigenic Clostridium difficile occurred in 12% of recipients of HPC transplant on admission to the hospital [6]. In addition, these patients are immunocompromised, receive extensive exposure to broad spectrum antimicrobials before and after HPC transplant, have compromise of the integrity of the intestinal mucosa due to the high dose chemoradiation given to the patients as part of transplant preparative regimens, and also often have very prolonged hospital stay [7][8][9].…”

Risk of Clostridium difficile Infection in Hematology-Oncology Patients Colonized With Toxigenic C. difficile

“…Jain T et al , 3 and Bruminhent et al , 4 reported a 12% and a 10.7% colonization rate at hospital admission, respectively, among their BMT population. Taken together, these studies suggest that the heme/BMT patient population is a significant reservoir of Clostridium difficile colonization, at least in large academic medical centers in the Midwest.…”

Clostridium difficile colonization in preoperative colorectal cancer patients

“…Toxigenic strains release exotoxins TcdA and TcdB to result in colitis and other diseases. Prevalence of C. difficile colonization for ICU patients [8], cancer patients [9, 10], patients undergoing hematopoietic stem cell transplantation [11, 12], residents in long-term care facilities [13], and healthy people [14] has been previously reported. The rates of C. difficile colonization in adult patients are different in different regions, but significantly lower than those in children [15].…”