Clostridium difficile Infection in Liver Transplant Recipients: A Retrospective Study of Rates, Risk Factors and Outcomes

Abstract

Clostridium difficile infection (CDI) occurs in 3-7% of liver transplant recipients (LTR). However, few data exist on the recent epidemiology, predictors and outcomes of CDI in LTR. A cohort study was performed including LTR from 2000 to 2010 at a tertiary care hospital in Detroit. CDI was defined as diarrhea with a stool C. difficile positive test. Data analyzed included demographics, comorbidities, length of stay (LOS), severity of CDI, rates of recurrence (<12 weeks), relapse (<4 weeks) and overall mortality. Predictors of CDI were calculated using Cox proportional hazard model; 970 LTR were followed for years. Overall prevalence of CDI was 18.9%. Incidence of CDI within 1 year of transplant was 12.4%. Severe CDI occurred in 29.1%. CDI recurrence and relapse rates were 16.9% and 9.7%, respectively. Independent predictors of CDI were year of transplant (hazard ratio [HR] 1.137, 95% confidence interval [CI] 1.06-1.22; p < 0.001), white race (105/162 whites, HR 1.47, 95% CI 1.03-2.1; p ¼ 0.035), Model for End-Stage Liver Disease score (HR 1.03, 95% CI 1.01-1.045, p ¼ 0.003) and LOS (HR 1.01, 95% CI 1.005-1.02, p < 0.001). Significant mortality was observed among LTR with CDI compared to those without CDI (p ¼ 0.003). We concluded that CDI is common among LTR and is associated with higher mortality.

Clostridium difficile infection in patients with liver disease: a review

“…However, one review [15] and several both nationwide and single-or multicenter studies have reported higher prevalence rates of CDI in hospitalized cirrhotics or LT recipients, and there is increasing recognition of these patients as a high-risk population for acquiring CDI [6][7][8][12][13][14][15][16]. Besides hospital-acquired CDI (when symptom onset takes place more than 48 h after admission to a hospital), community-acquired CDI (symptom onset occurs in the community or within 48 h of admission to a hospital) [17] has also been reported in cirrhotic patients [18].…”

“…Paralleling the increased incidence of CDI in the general population, there has been increased interest in CDI among patients with liver disease, particularly in those with liver cirrhosis and liver transplant (LT) recipients [6][7][8]. Patients with cirrhosis and LT are at particular risk for developing CDI because of their frequent and prolonged hospitalizations, antibiotic and PPIs use, multiple comorbidities, and immunosuppressant therapy [6][7][8][9][10].…”

“…Patients with cirrhosis and LT are at particular risk for developing CDI because of their frequent and prolonged hospitalizations, antibiotic and PPIs use, multiple comorbidities, and immunosuppressant therapy [6][7][8][9][10]. Altered immune mechanisms and gut microflora in patients with liver disease predispose to various bacterial infections, including CDI [11].…”

“…Clinical and laboratory diagnoses of CDI are similar in the liver disease and non-liver disease populations. Several studies have reported that both cirrhotic patients and LT recipients with CDI are at a higher risk of worse outcomes than those without CDI [6][7][8][12][13][14].…”

Infections After Orthotopic Liver Transplantation

“…25 In addition to MDR infections, frequent antibiotic use and systemic immunosuppression facilitate frequent clostridium difficile (estimated at 3-7% incidence) after OLT. 26 …”