Clostridioides difficile infection-associated cause-specific and all-cause mortality: a population-based cohort study

Anti-interleukin-23 treatment linked to improved Clostridioides difficile infection survival

Clostridioides difficile is a leading cause of healthcare-associated infection, and an unacceptably high proportion of patients with C. difficile infection die despite conventional antibiotic treatment. Host-directed immunotherapy has been proposed as an ideal treatment modality for C. difficile infection to mitigate the underlying toxin-mediated pathogenic immune response while sparing protective gut microbes. Interleukin-23 monoclonal antibody inhibitors are used extensively to control pro-inflammatory Th17 immune pathways in psoriasis and inflammatory bowel disease that are similarly important during C. difficile infection. We used a large retrospective electronic health record database to test the hypothesis that hospitalized patients with C. difficile infection who are on anti-IL-23 treatment will have improved survival compared to patients without anti-IL-23. A total of 9,301 anti-IL-23 patients had significantly lower probability of all-cause death within 30 d (0.54%) compared with 1:1 propensity-matched control patients (3.1%). IL-23 inhibition is a promising adjunct to C. difficile treatment, and further clinical trials repositioning anti-IL-23 monoclonal antibodies from psoriasis and inflammatory bowel disease to C. difficile infection are warranted.

Proton pump inhibitors and the risk of Clostridioides difficile infection: A systematic review and dose-response meta-analysis

BACKGROUND

Clostridioides difficile is a leading cause of healthcare-associated infections globally with proton pump inhibitor (PPI) use as important modifiable risk factor. This study aimed to systematically synthesise global evidence on the dose-response relationship of PPI usage and the Clostridioides difficile infection (CDI) risk and to identify potential safe thresholds of PPI usage regarding CDI.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched for longitudinal studies regarding PPIs and CDI. Aggregated data were included in two separate two-stage random-effects dose-response meta-analyses regarding Defined Daily Dose (DDD) and PPI therapy duration. Pooled adjusted relative risks (RRs) with 95% confidence intervals compared to non-users of PPIs were estimated.

FINDINGS

Overall, 15 observational cohort and case-control studies were included with 7 studies (n=483,821) in the meta-analysis per DDD and 7 studies (n=516,441) per PPI therapy duration. The risk of bias was modest. Pooled dose-response estimates suggest linear trends with a RR of 1.05 (95% CI 0.89,1.23) per 10 mg DDD and of 1.02 (95% CI 1.00,1.05) per day of PPI therapy. Substantial residual heterogeneity was detected in both analyses (I2=91.4% per DDD and I2=99.4% per therapy duration), but inferring potential sources was limited.

INTERPRETATION

Our results indicate a possible increase in the risk of CDI with increasing dose and duration of PPI therapy. Underlying mechanisms and dosage thresholds for a clinically relevant risk increase remain unclear.

Outcomes of Fecal Microbiota Transplantation for Clostridioides difficile Infection in South Australia

Background

Fecal microbiota transplantation (FMT) sourced from a bank of prescreened anaerobically processed frozen donor stool has been available in South Australia since 2013. This study aimed to evaluate the real-world clinical and safety outcomes of FMT for recurrent, refractory, and/or severe or fulminant Clostridioides difficile infection (CDI) facilitated via this centralized facility.

Methods

Donor screening test data were prospectively collected on all donors who passed prescreening evaluations between April 2013 and August 2023. The South Australian FMT for CDI database prospectively recorded outcomes for consecutive patients who underwent FMT for CDI from August 2013 to May 2023 in South Australia.

Results

An overall 98 potential donors passed prescreening assessments and underwent laboratory screening tests: 32 (33%) had tests that failed, 5 (5%) had incomplete screening, and 61 (62%) passed. Detection of an extended-spectrum β-lactamase-producing organism (9/65, 14%) was the common reason for ineligibility following completion of screening tests. In total 220 cases of CDI were recorded, and follow-up data were available in 216. Primary cure occurred in 84% of cases (182/216): 88% (132/150) for recurrent CDI, 76% (50/66) for refractory CDI, 85% (51/60) for severe disease, and 65% (17/26) for fulminant disease. Repeat FMT was delivered in 23 of 34 cases (68%), with secondary cure in 74% (17/23 cases). Serious adverse events were observed in 6 patients overall (3%). No deaths were directly attributable to FMT.

Conclusions

FMT was safe and efficacious for management of recurrent and refractory CDI over a 10-year period in a real-world prospective Australian cohort. Further studies to optimize the use of FMT for severe and fulminant CDI are warranted.

Clostridioides difficile infection and recurrence in cancer patients (CIRCA): A multicentre, international study

OBJECTIVES

We aimed to describe the characteristics of Clostridioides difficile infection (CDI) in cancer patients, analysing risk factors for 90-day recurrence and attributable mortality.

METHODS

Retrospective analysis on all CDI episodes from 2020 to 2022 in three Australian hospitals and one Spanish hospital. Logistic regression analyses were performed.

RESULTS

A total of 547 CDI episodes in cancer patients were documented. Treatment predominantly involved vancomycin (81.5%), followed by metronidazole (15.0%) and fidaxomicin (9.1%). Combined antibiotics were used in 61 (11.2%) episodes. The 90-day recurrence rate was 15.6%. Independent risk factors for CDI recurrence were female sex (OR 2.26, 95% CI 1.13-4.52), age >75 years (OR 2.69, 95% CI 1.30-5.59), dialysis (OR 5.15, 95% CI 1.45-18.27), vomiting at presentation (OR 0.06, 95% CI 0.01-0.55), colonic wall thickening in the CT abdomen (OR 2.42, 95% CI 1.06-5.49) and vancomycin therapy (OR 4.60, 95% CI 1.34-15.84). Overall, 90-day mortality was 22.3%, but attributable mortality was 4.9%. Risk factors for mortality attributed to CDI were age >65 years (OR 15.91, 95% CI 2.64-95.80), previous cerebrovascular disease (OR 20.27, 95% CI 3.12-131.84), antibiotic therapy within the last 30 days (OR 0.17, 95% CI 0.05-0.54), high-output diarrhoea (OR 6.68, 95% CI 1.68-26.56), high CRP-levels (OR 11.60, 95% CI 1.90-70.81) and need for treatment change (OR 6.65, 95% CI 2.20-20.08).

CONCLUSIONS

CDI recurrence rates among cancer patients remain significant. Nonetheless, fidaxomicin and other preventive strategies are seldom used. We identified several factors that could inform the implementation of these strategies in cancer patients.

Recognition, Diagnosis, and Treatment of Clostridioides difficile Enterocolitis Presenting Without Diarrhea: A Literature Review

Diarrhea, as the well-known clinical feature of Clostridioides difficile infection (CDI), may be absent at the initial presentation, leading to delays in diagnosis. The delay is due to both underrecognition of such presentations and the dependence of CDI diagnosis on stool samples. This review was conducted to evaluate the literature for CDI cases presenting without diarrhea, raise awareness about the possibility of CDI in the differential diagnosis regardless of diarrhea, and assemble relevant data to harmonize clinical approaches. The PubMED Medline database was used to conduct this literature review, focusing on reported CDI cases presenting without diarrhea. After exclusions, 22 articles were included for analysis, providing data for 48 cases. This paper will present the selected clinical data of these 48 patients and follow a real-life case with a clinical course of CDI including presentation, diagnosis, management, and outcomes. The excessive mortality and bowel resection rates of CDI patients presenting without diarrhea were the notable findings. Poor prognosis was possibly inflated by delayed diagnoses in an unfamiliar setting, emphasizing the importance of a high index of suspicion to allow early recognition of CDIs in the appropriate clinical context despite the absence of diarrhea.

Clostridioides difficile recovered from hospital patients, livestock and dogs in Nigeria share near-identical genome sequences

Genomic data on Clostridioides difficile from the African continent are currently lacking, resulting in the region being under-represented in global analyses of C. difficile infection (CDI) epidemiology. For the first time in Nigeria, we utilized whole-genome sequencing and phylogenetic tools to compare C. difficile isolates from diarrhoeic human patients (n=142), livestock (n=38), poultry manure (n=5) and dogs (n=9) in the same geographic area (Makurdi, north-central Nigeria) and relate them to the global C. difficile population. In addition, selected isolates were tested for antimicrobial susceptibility (n=33) and characterized by PCR ribotyping (n=53). Hierarchical clustering of core-genome multilocus sequence typing (cgMLST) allelic profiles revealed large diversity at the level HC150 (i.e. clusters of related genomes with maximally 150 pairwise allelic differences), which was previously shown to correlate with PCR ribotypes (RT). While several globally disseminated strains were detected, including HC150_1 (associated with RT078), HC150_3 (RT001) and HC150_3622 (RT014), 42 HC150 clusters (79%) represented unique genotypes that were new to the public genomic record, and 16 (30%) of these were novel PCR ribotypes. Considerable proportions of the C. difficile isolates displayed resistance to fluoroquinolones, macrolides and linezolid, potentially reflecting human and animal antibiotic consumption patterns in the region. Notably, our comparative phylogenomic analyses revealed human-human, human-livestock and farm-farm sharing of near-identical C. difficile genomes (≤2 core-genome allelic differences), suggesting the continued spread of multiple strains across human and animal (pig, poultry, cattle and dog) host populations. Our findings highlight the interconnectivity between livestock production and the epidemiology of human CDI and inform the need for increased CDI awareness among clinicians in this region. A large proportion of C. difficile strains appeared to be unique to the region, reflecting both the significant geographic patterning present in the C. difficile population and a general need for additional pathogen sequencing data from Africa.

Clinical Characteristics and Outcomes of Clostridioides difficile Infection in Cancer Patients From a Tertiary Care Hospital

Objective The objective of this study is to investigate the predisposing factors, disease course, potential complications, role of primary prophylaxis, and overall clinical outcomes of Clostridioides difficile infection (CDI) in cancer patients. Methods The study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. We analyzed the medical records of cancer patients diagnosed with CDI from July 2015 to July 2024 and collected data about demographic characteristics, clinical presentation, predisposing factors, treatment, complications, and mortality rates. We used SPSS version 25 (IBM Corp., Armonk, NY) for data analysis. Results Out of 61 patients, 55.7% (n=34) were men, and most of the patients belonged to the age group of 41-65 years (49.1%; n=30). Of the patients, 34.4% (n=21) had underlying hematological malignancy, while the majority of patients (63.9%; n=39) had underlying solid organ malignancy. A total of 45.9% (n=28) of patients had mild severity, whereas 16.3% (n=10) and 6.55% (n=4) were at severe and fulminant stages of CDI, respectively. The creatinine levels of 80.3% (n=49) of patients were less than 1.5 mg/dL. We also observed the prior antimicrobial use, previous hospitalization within the last four weeks, recent chemotherapy, and use of proton pump inhibitors (PPIs)/H2 antagonists in the past four weeks as predisposing factors in 78.6% (n=48), 72.1% (n=44), 55.7% (n=34), and 75.4% (n=46) of patients, respectively. A greater proportion of patients (68.8%; n=42) had hospital/ICU stays of less than 15 days. Of the patients, 29.6% (n=18) had comorbid conditions such as diabetes mellitus (DM), chronic kidney disease (CKD), hypertension (HTN), ischemic heart disease (IHD), hepatitis, and atrial fibrillation. Oral vancomycin was administered as the primary treatment in 78.6% (n=48) of patients. We noted the resolution of symptoms in 91.8% (n=56) of patients, while 83.6% (n=51) of patients developed no complications. Additionally, the radiological findings of the patients were negative for toxic megacolon. Moreover, 4.91% (n=3) of patients had recurrent infections, whereas all-cause 30-day mortality was 13.1% (n=8). The mortality rate was higher in patients with solid organ tumors (17.9%; n=7) as compared to those having hematological malignancy (4.76%; n=1). Regression analysis showed that recent chemotherapy had an odds ratio (OR) of 11.550 (95% confidence interval {CI}: 1.332-100.9; p=0.998). Conclusion Cancer patients, especially those with solid tumors presenting with symptoms suggestive of CDI and prior chemotherapy exposure, need careful evaluation and preemptive treatment as CDI-related mortality is higher in cancer patients. Early diagnosis and treatment in this population can be lifesaving. Moreover, all cancer patients should receive CDI prophylaxis when indicated.

Gene Expression Dysregulation in Whole Blood of Patients with Clostridioides difficile Infection

Clostridioides difficile (C. difficile) is a global threat and has significant implications for individuals and health care systems. Little is known about host molecular mechanisms and transcriptional changes in peripheral immune cells. This is the first gene expression study in whole blood from patients with C. difficile infection. We took blood and stool samples from patients with toxigenic C. difficile infection (CDI), non-toxigenic C. difficile infection (GDH), inflammatory bowel disease (IBD), diarrhea from other causes (DC), and healthy controls (HC). We performed transcriptome-wide RNA profiling on peripheral blood to identify diarrhea common and CDI unique gene sets. Diarrhea groups upregulated innate immune responses with neutrophils at the epicenter. The common signature associated with diarrhea was non-specific and shared by various other inflammatory conditions. CDI had a unique 45 gene set reflecting the downregulation of humoral and T cell memory functions. Dysregulation of immunometabolic genes was also abundant and linked to immune cell fate during differentiation. Whole transcriptome analysis of white cells in blood from patients with toxigenic C. difficile infection showed that there is an impairment of adaptive immunity and immunometabolism.

A Three-Year Analysis of Mortality in Clostridioides difficile Patients in a Tertiary Center

BACKGROUND/OBJECTIVES

Clostridioides difficile, an anaerobic bacillus ubiquitous in nature, is the leading cause of hospital-acquired diarrhoea and one of the main causes of mortality by nosocomial infections. We aimed to identify the main predictors of the risk of dying and the characteristics of a three-year cohort of patients hospitalised in our clinic that eventually had an unfavourable outcome.

METHODS

We collected retrospectively available data for all patients hospitalised between January 1, 2021, and December 31, 2023. The characteristics of the patients who died after the CDI (Clostridioides difficile infection) were analysed and compared with those of the patients who survived.

RESULTS

In the three-year interval mentioned above, 1086 patients had the main or secondary diagnosis of CDI. Of these, 97 patients (8.93%) died. The overall mortality for the same period was 2.62%. Eight patients (8.24%) who died had the primary diagnosis of CDI, while in the entire group, the percentage of patients with a primary diagnosis was 54.7%. Statistically significant differences between the groups of deceased and survivor patients were found for the following parameters: age (p<0.001, 95% CI (confidence interval): 12.5-20.5), previous CDI episodes (p=0.033, 95% CI: 0.014-0.329), and for the following parameters measured at admission: systolic blood pressure, quick sepsis-related organ failure assessment (qSOFA), leucocyte count, haemoglobin, creatinine, albumin, potassium, INR (international normalised ratio), CRP (C-reactive protein), fibrinogen, and procalcitonin. The number of hospitalisation days for the patients who died was significantly higher (p<0.001, 95% CI: 4.3-12.6.).

CONCLUSIONS

We identified the characteristics that significantly differentiated the patients who died from those who survived. Mortality is significantly higher in the group of patients with CDI than that in the other hospitalised patients.

Decreased Phagocytosis and Intracellular Killing of Bacteria in Leukocytes of Geriatric Patients with Clostridioides difficile Infections

INTRODUCTION

Patients suffering from a Clostridioides difficile infection have a higher overall mortality than patients with similar comorbidities.

METHODS

Whole blood samples of 15 patients with C. difficile enteritis and 15 control patients matched for age and sex were used to analyze the capacity of blood phagocytes to internalize and kill encapsulated Escherichia (E.) coli. The median age of C. difficile patients and control patients was 81 and 82 years, respectively. Blood samples were co-incubated with E. coli for 15 or 30 min. After 15 min of co-incubation, extracellular bacteria were killed by gentamicin for 15-45 min. Then eukaryotic cells were lysed with distilled water, and the number of intracellular bacteria per ml whole blood was determined by quantitative plating on agar plates. Both groups were compared by Mann-Whitney U test.

RESULTS

After 15 or 30 min of co-incubation, blood phagocytes from patients with C. difficile enteritis showed a reduced density of phagocytosed or adherent bacteria in comparison to blood phagocytes from control patients (15 min: p = 0.046, 30 min: p = 0.005). The density of intracellular bacteria decreased less rapidly over time in the blood from C. difficile patients (median Δlog CFU/mL × h [25th/75th percentile] -0.893 [-1.893/-0.554] vs. -1.483 [-2.509/-1.028]; p = 0.02). In line with these results, the percentage of intracellularly killed bacteria was decreased in phagocytes from C. difficile-infected patients compared to controls (median intracellular killing rate 64.3% for blood phagocytes from C. difficile patients vs. 81.9% for blood phagocytes from control patients within 30 min of co-incubation, p = 0.048).

CONCLUSION

Blood phagocytes from patients with C. difficile enteritis exhibited a reduced capacity to phagocytose and kill bacteria in comparison to blood phagocytes from age- and sex-matched control patients. Patients with C. difficile infection may have a higher disposition to develop infectious diseases than age- and sex-matched control patients.

Prediction of 28-Day All-Cause Mortality in Heart Failure Patients with Clostridioides difficile Infection Using Machine Learning Models: Evidence from the MIMIC-IV Database

INTRODUCTION

Heart failure (HF) may induce bowel hypoperfusion, leading to hypoxia of the villa of the bowel wall and the occurrence of Clostridioides difficile infection (CDI). However, the risk factors for the development of CDI in HF patients have yet to be fully illustrated, especially because of a lack of evidence from real-world data.

METHODS

Clinical data and survival situations of HF patients with CDI admitted to ICU were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database. For developing a model that can predict 28-day all-cause mortality in HF patients with CDI, the Recursive Feature Elimination with Cross-Validation (RFE-CV) method was used for feature selection. And nine machine learning (ML) algorithms, including logistic regression (LR), decision tree, Bayesian, adaptive boosting, random forest (RF), gradient boosting decision tree, XGBoost, light gradient boosting machine, and categorical boosting, were applied for model construction. After training and hyperparameter optimization of the models through grid search 5-fold cross-validation, the performance of models was evaluated by the area under curve (AUC), accuracy, sensitivity, specificity, precision, negative predictive value, and F1 score. Furthermore, the SHapley Additive exPlanations (SHAP) method was used to interpret the optimal model.

RESULTS

A total of 526 HF patients with CDI were included in the study, of whom 99 cases (18.8%) experienced death within 28 days. Eighteen of the 57 variables were selected for the model construction algorithm for model construction. Among the ML models considered, the RF model emerged as the optimal model achieving the accuracy, F1-score, and AUC values of 0.821, 0.596, and 0.864, respectively. The net benefit of the model surpassed other models at 16%-22% threshold probabilities based on decision curve analysis. According to the importance of features in the RF model, red blood cell distribution width, blood urea nitrogen, Simplified Acute Physiology Score II, Sequential Organ Failure Assessment, and white blood cell count were highlighted as the five most influential variables.

CONCLUSIONS

We developed ML models to predict 28-day all-cause mortality in HF patients associated with CDI in the ICU, which are more effective than the conventional LR model. The RF model has the best performance among all the ML models employed. It may be useful to help clinicians identify high-risk HF patients with CDI.

Molecular Characterization and Potential Host-switching of Swine Farm associated Clostridioides difficile ST11

OBJECTIVE

To conduct molecular prevalence and genetic polymorphism analysis of 24 Swine Farm associated C. difficile ST11 strains, in addition to other representative sequenced ST strains.

METHODS

The collected C. difficile strains underwent whole genome sequencing and bioinformatic analysis using the illumina NovaSeq platform, SPAdes, Prokka, MOB-suite, and FastTree. Virulence and antibiotic resistance genes were identified through NCBI Pathogen Database. Cytotoxicity tests were conducted on HT-29 cells and Vero cells to verify the function of toxin A and toxin B.

RESULTS

The most prevalent resistance genes in ST11 were found to be against β-lactamases, aminoglycosides, and tetracycline. A C. difficile isolate (strain 27) with tcdA deletion and high antibiotic resistance genes was far apart from other swine farm associated ST11 isolates in the phylogenetic branch. The remarkable genetic similarity between animal and human C. difficile strains suggests potential transmission of ST11 strains between animals and humans. The plasmid replicon sequences repUS43 were identified in all ST11 strains except one variant (strain 27), and 91.67% (22/24) of these were assessed by MOB-typer as having mobilizable plasmids.

CONCLUSION

Swine farm associated C. difficile ST11 carried fewer virulence genes than ST11 strains collected from NCBI database. It is critical to monitor the evolution of C. difficile strains to understand their changing characteristics, host-switching, and develop effective control and prevention strategies.

"Primum, non nocere": The Epidemiology of Toxigenic Clostridioides difficile Strains in the Antibiotic Era-Insights from a Prospective Study at a Regional Infectious Diseases Hospital in Eastern Europe

Clostridioides difficile infection (CDI), though identified nearly five decades ago, still remains a major challenge, being associated with significant mortality rates. The strains classified as hypervirulent, notably 027/NAP1/BI, have garnered substantial attention from researchers and clinicians due to their direct correlation with the severity of the disease. Our study aims to elucidate the significance of toxigenic Clostridioides difficile (CD) strains in the clinical and therapeutic aspects of managing patients diagnosed with CDI. We conducted a single-center prospective study, including patients with CDI from north-eastern Romania. We subsequently conducted molecular biology testing to ascertain the prevalence of the presumptive 027/NAP1/BI strain within aforementioned geographic region. The patients were systematically compared and assessed both clinically and biologically, employing standardized and comparative methodologies. The study enrolled fifty patients with CDI admitted between January 2020 and June 2020. Among the investigated patients, 43 (86%) exhibited infection with toxigenic CD strains positive for toxin B genes (tcdB), binary toxin genes (cdtA and cdtB), and deletion 117 in regulatory genes (tcdC), while the remaining 7 (14%) tested negative for binary toxin genes (cdtA and cdtB) and deletion 117 in tcdC. The presence of the presumptive 027/NAP1/BI strains was linked to a higher recurrence rate (35.56%, p = 0.025), cardiovascular comorbidities (65.1% vs. 14.2%, p = 0.016), and vancomycin treatment (55.8% vs. 14.3%, p = 0.049). The findings of our investigation revealed an elevated incidence of colitis attributed to presumptive 027/NAP1/BI. Despite the prevalence of the presumptive 027 strain and its associated heightened inflammation among the patients studied, no significant differences were observed regarding the clinical course or mortality outcomes.

Clostridioides difficile infection, recurrence and the associated healthcare consumption in Sweden between 2006 and 2019: a population-based cohort study

BACKGROUND

Clostridioides difficile infection (CDI) causes a major burden to individuals and society, yet the impact may vary depending on age, sex, underlying comorbidities and where CDI was acquired (hospital or community).

METHODS

This Swedish nationwide population-based cohort study (2006-2019) compared all 43,150 individuals with CDI to their 355,172 matched controls (first year and entire follow-up). Negative binomial regression models compared the cumulated length of stay, number of in-hospital admissions, outpatient visits and prescriptions after the first CDI episode expressed as incidence rate ratios (IRR) and 95% confidence intervals for the entire follow-up.

RESULTS

Overall, 91.6% of CDI cases were hospital acquired, and 16.8% presented with recurrence(s); 74.8%of cases were ≥ 65 years and 54.2% were women. Compared to individuals without CDI, in-hospital stay rates were 18.01 times higher after CDI (95% CI 17.40-18.63, first-year: 27.4 versus 1.6 days), 9.45 times higher in-hospital admission (95% CI 9.16-9.76, first-year: 2.6 versus 1.3 hospitalisations), 3.94 times higher outpatient visit (95% CI 3.84-4.05, first-year: 4.0 versus 1.9 visits) and 3.39 times higher dispensed prescriptions rates (95% CI 3.31-3.48, first-year: 25.5 versus 13.7 prescriptions). For all outcomes, relative risks were higher among the younger (< 65 years) than the older (≥ 65 years), and in those with fewer comorbidities, but similar between sexes. Compared to those without recurrence, individuals with recurrence particularly showed a higher rate of hospital admissions (IRR = 1.18, 95% 1.12-1.24). Compared to community-acquired CDI, those with hospital-acquired CDI presented with a higher rate of hospital admissions (IRR = 7.29, 95% CI 6.68-7.96) and a longer length of stay (IRR = 7.64, 95% CI 7.07-8.26).

CONCLUSION

CDI was associated with increased health consumption in all affected patient groups. The majority of the CDI burden could be contributed to hospital-acquired CDI (~ 9/10), older patients (~ 3/4) and those with multiple comorbidities (~ 6/10 Charlson score ≥ 3), with 1/5 of the total CDI burden contributed to individuals with recurrence. Yet, relatively speaking the burden was higher among the younger and those with fewer comorbidities, compared to their peers without CDI.

Clostridioides difficile recurrence in individuals with and without cancer: a Swedish population-based cohort study

PURPOSE

Patients with cancer are vulnerable to Clostridioides difficile infection (CDI) due to their disease, treatment and regular hospital contact, yet if CDI-recurrence is more common remains unclear, and differences among cancer types remain unexplored.

METHODS

This Swedish nationwide population-based cohort included all 43,150 individuals with recorded CDI (2006-2019) to assess CDI-recurrence in individuals with and without cancer, with binary multivariable logistic regression, stratified by anatomical location, and survival status.

RESULTS

Compared to those without cancer (N = 29,543), ongoing cancer (diagnosis < 12 months; N = 3,882) was associated with reduced recurrence (OR = 0.81, 95% CI 0.73-0.89), while there was no association with cancer history (diagnosis ≥ 12 months; N = 9,725). There was an increased 8-week all-cause mortality (Ongoing cancer: OR = 1.58, 95% CI 1.43-1.74; Cancer history: OR = 1.45, 95% CI 1.36-1.55) compared to those without cancer. Among CDI-survivors, those with ongoing cancer presented with a decreased odds of recurrence (OR = 0.84, 95% CI 0.76-0.94), compared to those without cancer history, with no association for those with cancer history (OR = 1.04, 95% CI 0.97-1.1). Large variations were seen across cancer types, with the highest observed proportion of recurrence in oral and mesothelial cancer, and the lowest for esophageal cancer, although no statistically significant OR were found.

CONCLUSION

The population-based study indicates that individuals with cancer may have fewerrecurrences than expected, yet variations by cancer type were large, and mortality was high.

The combined effect of systemic antibiotics and proton pump inhibitors on Clostridioides difficile infection and recurrence

BACKGROUND

Antibiotics and proton pump inhibitors (PPI) are recognized risk factors for acquisition and recurrence of Clostridioides difficile infection (CDI), yet combined effects remain unclear.

OBJECTIVES

To assess the short- and long-term effects of antibiotics and PPIs on CDI risk and recurrence.

METHODS

Population-based study including all 43 152 patients diagnosed with CDI in Sweden (2006-2019), and 355 172 matched population controls without CDI. The impact of antibiotics and PPIs on CDI risk and recurrence was explored for recent (0-30 days) and preceding (31-180 days) use prior to their first CDI diagnosis, using multivariable conditional logistic regression presented as odds ratios (ORs) and 95% confidence interval, adjusted for demographics, comorbidities and other drugs.

RESULTS

Compared to controls, the combined effect of recent PPIs and antibiotics [ORAB+PPI = 17.51 (17.48-17.53)] on CDI risk was stronger than the individual effects [ORAB = 15.37 (14.83-15.93); ORPPI = 2.65 (2.54-2.76)]. Results were less pronounced for exposure during the preceding months. Dose-response analyses showed increasing exposure correlated with CDI risk [recent use: ORAB = 6.32 (6.15-6.49); ORPPI = 1.65 (1.62-1.68) per prescription increase].Compared to individuals without recurrence (rCDI), recent [ORAB = 1.30 (1.23-1.38)] and preceding [ORAB = 1.23 (1.16-1.31); ORPPI = 1.12 (1.03-1.21)] use also affected the risk of recurrence yet without significant interaction between both. Recent macrolides/lincosamides/streptogramins; other antibacterials including nitroimidazole derivates; non-penicillin beta lactams and quinolones showed the strongest association with CDI risk and recurrence, particularly for recent use. PPI use, both recent and preceding, further increased the CDI risk associated with almost all antibiotic classes.

CONCLUSION

Recent and less recent use of PPIs and systemic antibiotics was associated with an increased risk of CDI, particularly in combination.