Risk of Recurrent Clostridium difficile Infection: Impact of Diagnostics and Treatment
Methods: We used active laboratory- and population-based surveillance data in metro Atlanta to identify a cohort of patients aged ≥ 18 years who developed an initial CDI (iCDI) from January 2010-September 2013. iCDI was defined as the first C. difficile-positive specimen by either molecular or toxin assay during study period. Patients were excluded from cohort if a prior CDI was identified from September-December 2009. Each iCDI patient was followed up for at least 3 months for recurrent CDI (rCDI), defined as a C. difficile-positive specimen >14 days from a previous positive test. A descriptive analysis of patients with rCDI was performed. Cox regression model was used on a random sample of iCDI patients stratified by age and gender to determine adjusted hazard ratios (HR) for recurrence based on iCDI treatment.
Results: Of 11,945 iCDI cases identified, 22.0% developed a first recurrence, 7.0% developed a second recurrence, and 2.8% developed three or more recurrences. The median time to 1st recurrence was 39 days (IQR: 24-85 days), and 63% occurred within 2 months of iCDI and 94% within a year. Diagnosis was made using a molecular assay in 49% of iCDI, 54% 1st, 57% 2nd and 61% of 3rd recurrences. The risk for a subsequent CDI was higher in those with one recurrence compared to those without any recurrences (HR 1.56, p<0.01). For every 10-year increase in age the HR was 1.12 (p<0.01) for 1st recurrence and 1.05 (p=0.01) for 2ndrecurrence. Of the 1,814 sampled cases, controlling for age, gender and diagnostic method, rCDI rates were similar in those treated with either metronidazole or vancomycin alone (p=0.13).
Conclusion: Almost a quarter of iCDI cases developed recurrent disease. However, only a small proportion of cases had multiple recurrences and may benefit from FMT. The uptake of molecular diagnostics by clinical laboratories may increase detection of real or perceived recurrences. Additional studies are needed to further evaluate the link between more sensitive diagnostics and initial therapeutic choices with risk of CDI recurrence.
S. C. Reddy,
W. Baughman, None
F. C. Lessa, None
M. M. Farley, None
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