Hospital-Onset Clostridium difficile Infection Rates in Persons with Cancer or Hematopoietic Stem Cell Transplant: A C3IC Network Report

Abstract

A multicenter survey of 11 cancer centers was performed to determine the rate of hospital-onset Clostridium difficile infection (HO-CDI) and surveillance practices. Pooled rates of HO-CDI in patients with cancer were twice the rates reported for all US patients (15.8 vs 7.4 per 10,000 patient-days). Rates were elevated regardless of diagnostic test used.In 2011, an estimated 1.6 million people underwent treatment for cancer. 1 Clostridium difficile is the most common bacterial cause of healthcare-associated diarrhea in persons receiving chemotherapy for cancer. Several risk factors in this population raise the risk of C. difficile infection (CDI). 2,3 In the last decade, with the emergence of BI/NAP1 strain the incidence and severity of CDI increased across North America and Europe, and the need for widespread surveillance became more important than ever. With the advent of public reporting for CDI, comparison of rates across centers will occur and may not take into account differences in patient populations. Therefore, we sought to determine the rate of hospital-onset (HO)-CDI and surveillance practices in a population of HSCT recipients and patients with cancer. Establishment of a benchmark for this large but unique patient group will assist both infection control practitioners and concerned consumers as they compare rates across states and hospitals. METHODS RESULTSA total of 11 centers participated in the survey. Hospital characteristics are shown in Table 2. Among the centers, the number of oncology beds ranged from 22 to 600 (median, 100 beds); HSCT beds, 6-80 (median, 26 beds). PCR was the most common detection method (6), followed by EIA (4) and CTA (1). Six centers are located in states where C. difficile is a reportable healthcare-associated infection (HAI). Rates of HO-CDIA case of HO-CDI was defined as a positive result of a laboratory assay for C. difficile toxin A and/or B following in-patient admission. The cutoff used was >48 hours at 5 centers and >72 hours at 6 centers.Centers using PCR as detection method had a higher median HO-CDI rate (1.72 per 1,000 patient-days) compared to EIA (0.9 per 1,000 patient-days; Figure 1). Among the centers that use PCR, the median HO-CDI rate was highest when the 48-hour cutoff from admission was used to define an HO-CDI case: 2.2 per 1,000 patient-days (more than 48 hours) and 1.57 per 1,000 patient-days (more than 72 hours). Relapse versus second new infectionMost centers followed the ad hoc C. difficile surveillance working group's criteria for recurrent infection. 6 In total, 7 of 9 centers that track recurrent cases consider an episode occurring more than 8 weeks after the index episode as a second new infection. One center uses 12 weeks as the interval and another center only considers a recurrent episode occurring at least 6 months after the index episode as second new infection. Duration of isolationIsolation practice for C. difficile varied widely across all centers. Two of 11 centers isolated patients with CDI for the entire duration of hos...

Clostridium Difficile Infection after Allogeneic Hematopoietic Stem Cell Transplant: Strain Diversity and Outcomes Associated with NAP1/027

“…Allogeneic HSCT recipients are among the most susceptible hosts for CDI (1, 3, 12, 15). Our study demonstrates that most CDIs occur around the time of conditioning and in the first week following stem cell infusion.…”

“…When used for diagnosis of CDI, molecular methods offer many advantages over widely used enzyme immunoassay (EIA) and cytotoxin neutralization assays, including higher sensitivity and rapid turnaround time, detection of colonization is much higher with these assays that detect the toxin gene. With doubling of C. difficile detection rates reported by many centers after implementation of PCR(3, 23), interpretation of a positive test in this population will have to be carefully evaluated in prospective studies that employ screening strategies and rigorously implemented clinical scoring systems to overcome the diagnostic challenge of distinguishing between active infection and colonization(3). …”

Clostridium difficile Infection after Adult Autologous Stem Cell Transplantation: A Multicenter Study of Epidemiology and Risk Factors

“…The current body of literature suggests that rates of CDI among patients with cancer are more than twice the rates reported for all hospitalized patients in the US [21]. Among auto HSCT recipients, these rates have ranged between 5-15% [9,10,22-24], with most infections occurring in the first 30 days of HSCT [9,10].…”

Fecal microbiota transplantation (FMT) for Clostridium difficile infection: Focus on immunocompromised patients

“…Cancer chemotherapy has been associated with CDI through its damaging effects to the intestinal mucosa and the alterations it causes to the gut microbiota [34,35]. A recent multicenter survey of 11 US cancer centers demonstrated that the pooled rate of hospital-onset CDI in patients with solid and hematological malignancies was 15.8 per 10,000 patient-days, twice the rate reported for all US patients [36]. In another large single center study, hematological malignancy was identified as an independent risk factor for CDI [37].…”

“…HSCT recipients are a severely immunosuppressed group of patients with the highest reported rates of CDI amongst those suffering of malignancy [36]. A US study of 999 autologous and allogeneic HSCT recipients found that CDI was common in the early post-transplant period with a 1-year incidence of 9.2% [28].…”