Incidence and Risk Factors of Recurrent Clostridioides difficile Infection in Patients With Cirrhosis

Abstract

INTRODUCTION: Clostridioides difficile infection (CDI) is common in patients with cirrhosis and is associated with poor outcomes. CDI risk factors in this population have been well characterized; however, risk factors of recurrent CDI (R-CDI) after treatment have not been explored. We sought to estimate the incidence of R-CDI and its associated risk factors in patients with cirrhosis. METHODS: We performed a cohort study of patients with cirrhosis hospitalized with CDI between 2012 and 2016. We collected patient characteristics, including detailed information on the CDI, features of the underlying liver disease, and outcomes including R-CDI, hospital readmission, and mortality. R-CDI was defined as CDI occurring 2–8 weeks after the initial episode. Cox proportional hazards model was used to identify variables independently associated with the outcomes. RESULTS: A total of 257 hospitalized patients with cirrhosis and CDI were included. CDI was community associated in 22.6%. The incidence of R-CDI was 11.9%. R-CDI was not significantly associated with medications at hospital admission or discharge. Independent risk factors of R-CDI included increased Charlson Comorbidity Index (hazard ratio [HR] 1.30; 95% confidence interval [CI]: 1.09–1.55) and use of lactulose (HR 2.58; 95% CI: 1.09–6.09). The 30-day readmission rate was 37%, and readmission was associated with increased Charlson Comorbidity Index (HR 1.12; 95% CI: 1.03–1.23) and Model for End-Stage Liver Disease score (HR 1.04; 95% CI: 1.01–1.07). The 90-day mortality was 22.8%. DISCUSSION: In patients with cirrhosis, R-CDI is associated with comorbidity burden and lactulose use. Attention to these factors might aid clinicians in efforts to prevent R-CDI and improve outcomes in this population.

Clostridioides difficile Infection in Liver Cirrhosis: A Concise Review

“…The impact of these agents on CDI in cirrhosis needs to be further supported in high-quality studies. A study showed risk factors for R-CDI in cirrhosis, including Charlson Comorbidity Index and lactulose use, which is aligned with the risk factors for CDI [ 21 ] ( Figure 1 ).…”

“…The incidence of R-CDI in patients with cirrhosis was studied in a cohort study conducted at Indiana University Hospital from 2012 to 2016, with an 11.9% incidence of R-CDI among those hospitalized with CDI in patients with cirrhosis [ 21 ].…”

“…Yet another study indicated that CDI was associated with increased 30-day mortality but not with increased overall mortality [ 48 ]. Alongside increased mortality, CDI could potentially carry an additional risk of complications, including sepsis [ 31 ], organ failure [ 31 ], portal vein thrombosis [ 62 ], and readmission [ 21 ]. Caution should be taken, as readmission is associated with increased severity of cirrhosis and mortality [ 21 , 40 ].…”

“…Alongside increased mortality, CDI could potentially carry an additional risk of complications, including sepsis [ 31 ], organ failure [ 31 ], portal vein thrombosis [ 62 ], and readmission [ 21 ]. Caution should be taken, as readmission is associated with increased severity of cirrhosis and mortality [ 21 , 40 ]. Studies on the outcomes of CDI in cirrhosis are summarized in Table 2 .…”

“…Infection is a significant comorbidity in patients with cirrhosis, increasing mortality risk [ 18 – 20 ]. Since risk factors for the development of CDI are also frequently reported in patients with cirrhosis [ 21 ], CDI is also a prevalent type of infection in cirrhosis and hurts the prognosis of patients. Cirrhosis with CDI have a worse prognosis and more extended hospital stays than those without CDI [ 22 ].…”