Characteristics of Patients With Initial Clostridioides difficile Infection (CDI) That Are Associated With Increased Risk of Multiple CDI Recurrences

Abstract

Background: Because interventions are available to prevent further recurrence in patients with recurrent Clostridioides difficile infection (rCDI), we identified predictors of multiple rCDI (mrCDI) in adults at the time of presentation with initial CDI (iCDI).

Methods: iCDI was defined as a positive C difficile test in any clinical setting during January 2018-August 2019 in a person aged ≥18 years with no known prior positive test. rCDI was defined as a positive test ≥14 days from the previous positive test within 180 days after iCDI; mrCDI was defined as ≥2 rCDI. We performed multivariable logistic regression analysis.

Results: Of 18 829 patients with iCDI, 882 (4.7%) had mrCDI; 437 with mrCDI and 7484 without mrCDI had full chart reviews. A higher proportion of patients with mrCDI than without mrCDI were aged ≥65 years (57.2% vs 40.7%; P < .0001) and had healthcare (59.1% vs 46.9%; P < .0001) and antibiotic (77.3% vs 67.3%; P < .0001) exposures in the 12 weeks preceding iCDI. In multivariable analysis, age ≥65 years (adjusted odds ratio [aOR], 1.91; 95% confidence interval [CI], 1.55-2.35), chronic hemodialysis (aOR, 2.28; 95% CI, 1.48-3.51), hospitalization (aOR, 1.64; 95% CI, 1.33-2.01), and nitrofurantoin use (aOR, 1.95; 95% CI, 1.18-3.23) in the 12 weeks preceding iCDI were associated with mrCDI.

Conclusions: Patients with iCDI who are older, on hemodialysis, or had recent hospitalization or nitrofurantoin use had increased risk of mrCDI and may benefit from early use of adjunctive therapy to prevent mrCDI. If confirmed, these findings could aid in clinical decision making and interventional study designs.

Figure 1.

Flow diagram depicting the selection of patients with initial Clostridioides difficile infection for chart review and inclusion in the analysis. Abbreviations: CDI, Clostridioides difficile infection; EIP, Emerging Infections Program. ^aPatients with community-onset CDI who underwent a full chart review were less likely than those without a chart review to be community-associated (71.0% vs 93.3%; P = .004), but there were no differences in the proportion who were female (P = .10), aged ≥65 y (P = .93), or who had multiple recurrent CDI (P = 1.00) or died within 180 d of initial CDI (P = .69). ^bPatients with healthcare facility-onset CDI (ie, hospital-onset or long-term care facility onset CDI) who had a full chart review were less likely than those without a chart review to be long-term care facility-onset (32.7% vs 38.5%; P = .004), but there were no differences in the proportion who were female (P = .19), aged ≥65 y (P = .32), or who had multiple recurrent CDI (P = .51), or died within 180 d of initial CDI (P = .48).