Clostridioides difficile Infection Among Patients Requiring Maintenance Hemodialysis

Abstract

Clostridioides difficile Infection Among Patients Requiring Maintenance Hemodialysis To the Editor: Clostridioides difficile is the most common cause of gastroenteritis-related death in the United States. Rates of C difficile infection (CDI) are increasing in the maintenance hemodialysis (HD) population. These patients are 2.5 times more likely to develop CDI and have 2fold higher mortality rates compared with the general population. Hospital costs and lengths of stay are also longer. There is a paucity of data pertaining to the clinical epidemiology of CDI among patients requiring maintenance HD. To improve the management and outcomes of CDI in this patient population, we characterized clinical factors associated with severe or fulminant CDI, compared with nonsevere CDI, and identified the subset of maintenance HD patients with CDI at highest risk for mortality. From January 2015 through December 2018, a retrospective cohort study among patients requiring maintenance HD with a diagnosis of CDI at admission to a 700and 255-bed tertiary-care hospital in Rhode Island was conducted. Approval from the ethics board was obtained (#1327710). Informed consent was waived because the study was retrospective. Only the first episode per patient was included. CDI was defined as a positive test result using the GeneXpert assay (Cepheid) and documentation of diarrhea. Infectious Diseases Society of America (IDSA) criteria were used to classify CDI severity. Nonsevere and severe CDI were defined as a white blood cell (WBC) count ≤ 15,000 cells/mL and WBC count ≥ 15,000 cells/ mL, respectively. Fulminant CDI required the presence of hypotension or shock, megacolon, or ileus. IDSA criteria also include serum creatinine values but these were excluded in the study definitions. IDSA guidelines were used to determine the appropriateness of CDI treatment. Clinical data and requirement for maintenance HD were collected using Theradoc (Premier, Inc), a clinical surveillance software used nationwide by infection preventionists to monitor infections within hospitals, and review of electronic medical records. Variables with P ≤ 0.05 on univariable analyses were included in a stepwise logistic and Cox regression model to identify independent variables associated with baseline characteristics and 60-day mortality, respectively. A total of 129 patients requiring maintenance HD were admitted with a primary diagnosis of CDI during the study period, of which 26 (20.2%) were recurrences and 103 (80%) were a first CDI episode. All patients had diarrhea and a positive GeneXpert assay result. A subset of patients had a second admitting diagnosis, including another infection, including bloodstream, skin or soft tissue, or lung (N = 26 [25.2%]); altered mental status