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Cirrhosis etiology may increase risk for recurrent C. difficile infection

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SAN DIEGO – Non-alcoholic steatohepatitis-related cirrhosis may be an independent risk factor for recurrent Clostridium difficile infections, according to findings presented at Digestive Disease Week.

“The incidence of C. difficile infection is increased in patients with cirrhosis and is associated with poor outcomes,” the researchers wrote. “Risk factors associated with C. difficile infection in cirrhosis include use of antibiotics and proton pump inhibitors, other infections and intensive care unit admission. While it is well known that patients with C. difficile infection are at risk for its recurrence, the characteristics of recurrent C. difficile infection in patients with cirrhosis remain unclear.”

Parkpoom Phatharacharukul, MD, of Indiana University School of Medicine, and colleagues therefore aimed to examine the rate of recurrent C. difficile infection and related risk factors among patients with cirrhosis who were hospitalized.

The researchers conducted a cohort study of patients with cirrhosis who were admitted to Indiana University Hospital for an initial episode of C. difficile infection between 2012 and 2016. Individuals were excluded if they had a previous C. difficile infection or inflammatory bowel disease or had received a liver transplantation.

Phatharacharukul and colleagues gathered data through manual chart review. Patients were followed for a minimum of 3 months following discharge from the hospital. The researchers obtained data on multiple variables, including baseline demographics, etiology, severity and complications of cirrhosis, hospital course, treatment for C. difficile infection and outcomes.

Recurrence was categorized as an episode of C. difficile infection that developed 2 to 8 weeks after onset of a prior incident. The researchers determined the rate of recurrence among patients with cirrhosis and used multivariable logistic regression to determine variables that independently correlated with recurrent C. difficile infection.

During the study period, 268 patients with cirrhosis and C. difficile infection were admitted to the hospital. Forty-nine of these patients died over the course of their hospitalization or were discharged to hospice; these individuals were excluded from the analysis.

The incidence rate of recurrent C. difficile infection was 12%.

A number of variables, including age, sex, race and liver disease severity, were similar among patients with and without recurrent C. difficile infections. The way in which patients acquired C. difficile infection – health care- vs. community-associated – was also similar between these groups.

The use of certain medications, including proton pump inhibitors, histamine-2 receptor antagonists, antibiotics (including spontaneous bacterial peritonitis prophylaxis) and lactulose at the time of discharge did not correlate with recurrent C. difficile infection. Additionally, the incidence of recurrent C. difficile infection among patients who received monotherapy with metronidazole as a first treatment for recurrent C. difficile infection compared with vancomycin with or without metronidazole were not significantly different (11% vs. 12%, respectively).

“Interestingly,” the researchers wrote, NASH-related cirrhosis “was a significant risk factor for recurrent C. difficile infection (OR, 3.36; 95% CI, 1.39-8.14).” Patients with NASH-related cirrhosis were older, more likely to be women and Caucasian and had a greater number of comorbidities.

NASH-related cirrhosis “was an independent risk factor for recurrent C. difficile infection in patients with cirrhosis,” the researchers wrote. “Further study is needed to confirm our observations and to understand their implications.” – by Julia Ernst, MS

Reference:

Phatharacharukul P, et al. Abstract Mo1523. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.

Disclosures: Phatharacharukul reports no relevant financial disclosures. Please see the abstract for a list of all other authors’ relevant financial disclosures.