Rarity of toxigenic Clostridium difficile infections after hematopoietic stem cell transplantation: implications for symptomatic management of diarrhea

Abstract

Summary:Diarrhea is a common complication of high-dose chemotherapy and hematopoietic stem cell transplantation (HSCT). The frequent and prolonged use of multiple antibiotics in this setting can predispose to infection with toxigenic Clostridium difficile and the development of pseudomembranous colitis. Anti-motility agents are usually not administered in this setting until C. difficile infection has been excluded. The objective of this study was to determine the incidence of C. difficile toxin (CDT) positivity at the time of initial diarrhea in HSCT recipients, and to see if the practice of ensuring negative CDT assays prior to initiating symptomatic management of diarrhea needs modification. One hundred and nineteen patients with malignant diseases undergoing autologous or allogeneic HSCT were studied to determine the incidence of diarrhea and CDT positivity with initial diarrhea. One hundred and nine (91%) had diarrhea. Of these, only seven (6%) were CDT+ at the time of initial diarrhea. The median interval between onset of diarrhea and starting symptomatic antidiarrheal therapy was 1 day. There were no significant differences between the patients with CDT+ diarrhea and the others in terms of timing or severity of diarrhea, number or duration of antibiotic usage, or leukocyte count. The infection resolved in all patients with metronidazole therapy. Our data suggest that the incidence of CDT+ diarrhea is low in HSCT recipients. Concern about C. difficile infection should not delay symptomatic therapy of initial diarrhea in HSCT recipients.

Incidence of Clostridium difficile-associated diarrhea before and after autologous peripheral blood stem cell transplantation for lymphoma and multiple myeloma

“…[3][4][5][6][7][8][9] The incidence of Clostridium difficile-associated diarrhea (CDAD) in patients undergoing APBSCT has been reported to be in the range of 5-7%. 1,2,6 A preliminary analysis from our group suggested that patients with multiple myeloma had a higher incidence of CDAD than reported previously. 7 The purpose of this study was to determine the incidence of CDAD in a larger cohort of patients who underwent APBSCT for multiple myeloma and to compare the incidence of CDAD in patients transplanted for multiple myeloma to patients transplanted for lymphoma.…”

“…11,12 Second, our study only included patients with lymphoma and multiple myeloma in contrast to the other two studies, which included patients with other diagnoses. 2,6 More than half of the patients in the study by Bilgrami et al 6 had solid tumors, while the study by Tomblyn et al 2 included patients with other hematologic malignancies. As discussed below, it is not clear if the underlying diagnosis can predispose patients to CDAD.…”

“…First, 90% of our patients were male, and the median age of our patients was 5 and 10 years older than in two previously published reports, which described the age of the population studied. 2,6 Increasing age has been a consistently noted risk factor, with more than tenfold increased risk for patients older than 60 years of age. 11,12 Second, our study only included patients with lymphoma and multiple myeloma in contrast to the other two studies, which included patients with other diagnoses.…”

“…1,2 The causes of diarrhea in patients undergoing autologous transplantation include inflammation of the intestinal mucosa owing to chemotherapy, the use of multiple medications such as prophylactic antimicrobials and infection. [3][4][5][6][7][8][9] The incidence of Clostridium difficile-associated diarrhea (CDAD) in patients undergoing APBSCT has been reported to be in the range of 5-7%.…”

Risk factors, outcomes and epidemiology associated with Clostridium difficile infection in patients with haematological malignancies in a tertiary care hospital in China

“…Reports show a 76-91 % incidence of diarrhoea in HSCT recipients (Tomblyn et al, 2002), and the incidence of CDI in these patients can be as high as 20 % (Bobak et al, 2008).…”