Evaluating Risk Factors for Clostridium difficile Infection in Adult and Pediatric Hematopoietic Cell Transplant Recipients
Although hematopoietic cell transplant (HCT) recipients are routinely exposed to classic risk factors of Clostridium difficile infection (CDI), few large studies have assessed CDI risk in these high-risk patients, and data for pediatric recipients are lacking. We aimed to determine incidence and risk factors for CDI in adult and pediatric allogeneic HCT recipients.
Patients receiving an allogeneic HCT from 2008-2012 at the Fred Hutchinson Cancer Research Center were included in this retrospective cohort study; those <1 year old or with CDI within 8 weeks pre-HCT were excluded. Patients were categorized by treating hospital ("adult" or "pediatric") and observed 100 days post-HCT for CDI, defined as diarrhea tested positive for C. difficile via PCR, cytotoxin assay, or dual enzyme immunoassays. We analyzed CDI risk factors with univariate and backward-selected multivariable Cox models. Post-hoc analyses among pediatric recipients addressed acquisition risk associated with outpatient housing.
Of 1182 HCT recipients, CDI was diagnosed in 17% (33/192) of pediatric recipients at an incidence of 20 per 10,000 patient-days, and 11% (107/990) of adult recipients at an incidence of 12 per 10,000. Pediatric recipients were diagnosed at a median of 51 days (interquartile range [IQR]: 5, 72) and adults at 16 days (IQR: 5, 49). Year of HCT was associated with CDI in pediatric recipients (p=.028), with 2012 driving this effect (hazard ratio [HR]: 3.99, p=.06); myeloablative conditioning increased CDI risk in adult recipients (HR: 1.81, p=.005). None of the following predicted CDI in either group: age, graft type, graft-versus-host disease (GVHD) prophylaxis, or acute GVHD severity. Increased incidence among pediatric recipients after discharge (Figure 1) led to post-hoc analyses suggesting greater risk of CDI acquisition in outpatient housing (HR: 1.90, p=.075).
Pediatric and adult allogeneic recipients are at high risk of CDI early post-HCT. Data linking pediatric CDI acquisition with outpatient housing resulted in infection control interventions at the facility. Since exposure differences between children and adults may contribute to incidence differences, separately evaluating these groups should be considered in future CDI studies.
A. Morrison, None
S. Butler-Wu, Thermo Fisher Scientific: Scientific Advisor, Salary
D. Zerr, None
K. Rogers, None
Z. Stednick, None
A. Magaret, None
A. Wald, Aicuris: Consultant, Consulting fee
Genocea: Investigator, Research support
Agenus: Investigator, Research support
Vical: Investigator, Research support
S. Pergam, Merck Research Laboratories: Consultant and Research Contractor, Consulting fee and Research support
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