Clostridium difficile infection in patients with liver disease: a review

Abstract

Over the past two decades, there has been a dramatic worldwide increase in both the incidence and severity of Clostridium difficile infection (CDI). 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 post liver transplantation. MEDLINE and several other electronic databases from January 1995 to December 2014 were searched in order to identify potentially relevant literature. Patients with cirrhosis and liver transplant recipients are at high risk for the development CDI because of antibiotics and proton pump inhibitors use, frequent and prolonged hospitalization, immunosuppressant therapy, and multiple comorbidities. Enzyme immunoassay to detect C. difficile toxins A and B in stool remains the most widely used test for CDI diagnosis, although, more recently, polymerase chain reaction (PCR)-based assays have become the preferred diagnostic test in many laboratories. Metronidazole and vancomycin, given orally, have proved to be effective in the treatment of CDI. Both cirrhotic patients and liver transplant recipients with CDI have longer length of hospital stay, increased mortality, and higher healthcare costs than those without CDI. A rapid diagnosis and adequate therapy of CDI are of paramount importance to improve liver disease patients' outcome. The aim of this review is to provide up-to-date information on the epidemiology, risk factors, pathogenesis, treatment, and outcomes in liver disease patients with CDI.

Outcomes associated with Clostridium difficile infection in patients with chronic liver disease

“…For CDI specifically, CLD associated immune dysfunction leads to an immunocompromised state due to altered immune response and dysbiosis of gut microbiota. [6, 7] Previous studies have shown that CDI in patients with CLD results in increases mortality, morbidity, and cost. [6, 11] This study confirms and extends these findings by demonstrating that mortality and cost are increased significantly in this patient population compared to patients with CDI without CLD.…”

“…[6, 7] Previous studies have shown that CDI in patients with CLD results in increases mortality, morbidity, and cost. [6, 11] This study confirms and extends these findings by demonstrating that mortality and cost are increased significantly in this patient population compared to patients with CDI without CLD. The observed worse outcomes in patients with CLD are likely due to a higher severity of underlying illness in this patient population compared to other chronically ill patients.…”

“…[4, 5] Patients with CLD tend to display less overt signs and symptoms of infection most likely due to underlying immune dysfunction. [6, 7] This may complicate treatment decisions as most severity risk stratification measures for CDI are based on host response to infection such as fever or leukocytosis. [8–10] Two previous studies have shown that CDI increases mortality, length of stay, and hospitalization costs in CLD patients.…”

Detection, Ribotyping and Antimicrobial Resistance Properties of Clostridium difficile Strains Isolated From The Cases of Diarrhea

“…C. difficile is a spore-forming, anaerobic, gram-positive bacillus bacterium which causes a wide spectrum of illnesses from asymptomatic colonization or mild diarrhea to fulminant disease characterized by toxic megacolon, sepsis, pseudomembranous colitis and death (2-4). C. difficile infection is less common in children than adults, but its prevalence is increasing in children (5-7).…”

Transplanting patients with active bacterial infection

“…Patients with cirrhosis are also at increased risk for Clostridium difficile infection (CDI), with a rising incidence that has run in parallel to the general population over the last two decades. CDI significantly impacts patient outcomes, including increased length of stay and decreased survival among patients with cirrhosis . A recent retrospective study of CDI among LT recipients showed that a large proportion of CDI occurred within 1 week post‐LT and was associated with lower overall survival .…”