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. 2014 Oct;20(10):1626-33.
doi: 10.1016/j.bbmt.2014.06.025. Epub 2014 Jun 25.

Clostridium difficile infection after allogeneic hematopoietic stem cell transplant: strain diversity and outcomes associated with NAP1/027

Mini Kamboj  1 , Kun Xiao  2 , Anna Kaltsas  3 , Yao-Ting Huang  2 , Janet Sun  2 , Dick Chung  2 , Saliangi Wu  4 , Anna Sheahan  2 , Kent Sepkowitz  3 , Ann A Jakubowski  5 , Genovefa Papanicolaou  3
Affiliations

Clostridium difficile infection after allogeneic hematopoietic stem cell transplant: strain diversity and outcomes associated with NAP1/027

Mini Kamboj et al. Biol Blood Marrow Transplant. 2014 Oct.

Abstract

Allogeneic hematopoietic stem cell transplantation (HSCT) recipients are at high risk for developing Clostridium difficile infection (CDI). We studied the incidence, risk factors, NAP1/027 prevalence, and clinical outcomes, including acute lower gastrointestinal graft-versus-host disease (GI GVHD), associated with early CDI in this population. A retrospective review was conducted of patients who underwent allogeneic HSCT at Memorial Sloan Kettering Cancer Center from January 1, 2005 to September 30, 2010. Early CDI was defined as infection occurring from day -10 to day +40 from stem cell infusion. Among 793 patients who received allogeneic HSCTs, early CDI occurred in 11.9%; 56% cases were between day -5 and day +5. Overall incidence was 25.2 cases/10,000 at-risk days. There was a high prevalence of NAP1/027 strains during peak incidence (61% in 2008). NAP1/027 was the most common strain in both adult and pediatric cases (24% and 23%, respectively). CDI was clinically mild, including those due to NAP1/027. Metronidazole was the primary treatment for 91 of 94 patients, 7 of 8 cases refractory to metronidazole had no response to vancomycin, and none was due to NAP1/027. Relapse of CDI was common (31%). The cumulative incidence of GI GVHD in patients with and without early CDI was 6.8% and 8%, respectively (P = .5). Most cases of CDI occurred during conditioning or immediately after transplant. Despite high prevalence of NAP1/027, we found only mild disease. Most patients were treated successfully with metronidazole, irrespective of NAP1/027 status. There was no significant association between early CDI and subsequent development of GI GVHD. This study demonstrates the high incidence of CDI early after allogeneic HSCT with wide diversity among infecting strains. Despite the high prevalence of NAP1/027, the disease is mild but relapses are common. No association was found between CDI and subsequent development of GI GVHD.

Keywords: Allogeneic hematopoietic stem cell transplantation; Clostridium difficile infection; Immunocompromised host; NAP1/027 strain.

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Conflict of interest statement

Conflict of interest: None for all authors

Figures

Figure 1
Figure 1
Rate of early CDI among allogeneic HSCT recipients at MSKCC from January 2005 to September 2010. CYT = Cytotoxin assay; GDH = Glutamate dehydrogenase assay
Figure 2
Figure 2
Frequency distribution of timing of early CDI cases in relation to timing from stem cell infusion
Figure 3
Figure 3
Distribution of MLST types from 42 CDI diagnosed from January 2008 to September 2010. Red triangles represent infections due to NAP1 /027 strain and blue boxes non-NAP1 infections, each horizontal bar connects unique ST types.
Figure 4
Figure 4
a. Cumulative incidence of acute lower GI GVHD (Grade ≥2) in patients with and without early CDI b. Cumulative incidence of acute lower GI GVHD (Grade ≥2) in patients with and without early CDI sorted by transplant type CONV = conventional; TCD = T-cell depleted; CDI = Clostridium difficile infection
Figure 4
Figure 4
a. Cumulative incidence of acute lower GI GVHD (Grade ≥2) in patients with and without early CDI b. Cumulative incidence of acute lower GI GVHD (Grade ≥2) in patients with and without early CDI sorted by transplant type CONV = conventional; TCD = T-cell depleted; CDI = Clostridium difficile infection
See this image and copyright information in PMC

References

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