Issue: July 2017
July 03, 2017
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Rise in multiply recurrent C. difficile increases demand for therapies

Issue: July 2017
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Between 2001 and 2011, the incidence of multiply recurrent Clostridium difficile infection increased significantly, which will likely increase the demand for therapies — such as fecal microbiota transplantation — to treat the condition, according to research published in Annals of Internal Medicine.

Perspective from Colleen R. Kelly, MD

“Incidence of [Clostridium difficile] is widely believed to have increased over the past 2 decades, with hospitalizations for the infection in the United States doubling between 2000 and 2010,” Gene K. Ma, MD, from the University of Pennsylvania Perelman School of Medicine, and colleagues wrote. “However, little is known about trends in incidence of recurrent CDI, particularly [multiply recurrent CDI (mrCDI)], which would be an indication for [fecal microbiota transplantation (FMT)]. Knowledge of the magnitude of this problem and projection of the potential demands on the health care system in the coming years are needed.”

Ma and colleagues conducted a retrospective cohort study to investigate whether the occurrence of mrCDI is increasing in proportion to CDI, as well as to identify risk factors for mrCDI. Using the OptumInsight Clinformatics Database, they identified 38,911,718 eligible patients who were commercially insured (median age, 31 years; 49.9% female). Of those, 45,341 developed CDI after a median follow-up of 1.9 years (median age, 46 years; 58.9% female), with 1,669 experiencing mrCDI.

Results indicated that between 2001 and 2012, there was a 42.7% increase (from 0.4408 to 0.6289 case) in the annual incidence of CDI per 1,000 person years and a 188.8% increase (from 0.0107 to 0.0309 case) in the annual incidence of mrCDI per 1,000 person-years. The extreme increase in mrCDI was independent of other known risk factors of CDI, apparent throughout the United States and dramatically exceeded the increased incidence of CDI. An increased risk for developing mrCDI was observed in older adults (median age, 56 vs. 49 years; adjusted OR per 10-year increase in age, 1.25 [95% CI, 1.21-1.29]), females (63.8% vs. 58.7%; aOR, 1.24 [95% CI, 1.11-1.38]) and those who used antibiotics (72.3% vs. 58.8%; aOR, 1.79 [95% CI, 1.59-2.01]), proton-pump inhibitors (24.6% vs. 18.2%; aOR, 1.14 [95% CI, 1.01-1.29]) or corticosteroids (18.3% vs. 13.7%; aOR, 1.15 [CI, 1-1.32]) within 90 days of CDI diagnosis. Further, those with chronic kidney disease (10.4% vs. 5.6%; aOR, 1.49 [95% CI, 1.24-1.8]) and who were diagnosed in a nursing home (2.1% vs. 0.6%; aOR, 1.99 [95% CI, 1.34-2.93]) were more likely to have mrCDI.

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“These data project an increasing demand for therapies to treat mrCDI, which will likely translate into greater use of FMT in the coming years,” Ma and colleagues concluded. “Although FMT is highly effective and apparently safe in the short term, the results of this study highlight the importance of establishing the long-term safety of FMT given the projected increase in demand for this therapy. In addition, these findings reveal avenues of further study that may help guide the modification of treatment algorithms to reduce the incidence of mrCDI.”

In a related editorial, Sameer D. Saini, MD, MS, and Akbar K. Waljee, MD, MSc, both from the VA Ann Arbor Center for Clinical Management Research and the University of Michigan, wrote that the findings by Ma and colleagues is an important beginning to better understanding mrCDI, its scope, epidemiology and risk factors, as well as developing a comprehensive approach to address the growing public health challenge. – by Alaina Tedesco

Disclosure: Ma and colleagues report primary funding from National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Allergy and Infectious Diseases. Saini reports receiving personal fees from FMS Inc. and grants from Veterans Affairs Health Services Research and Development. Waljee reports receiving support by a Veterans Affairs Health Services Research and Development Career Development Award.