C Difficile Infection Rates Low in Stroke Patients

Robert J. Brown, MD

New research shows the risk of developing clostridium difficile infections (CDI) is low in stroke patients.

A team, led by Robert J. Brown, MD, McGovern Medical School, UTHealth Baylor College of Medicine, identified the incidence, patient characteristics, clinical features, and outcomes of C difficile infections following stroke, including ischemic stroke (IS), intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (SAH).

The Need for Data

There is not much data available on the risk of developing a C difficile infection in stroke patients. In the study, the investigators examined hospital databases for patients with IS, ICH, or SAH between 2010-2014 and assessed patients who underwent polymerase chain reaction (PCR) testing for C diffiicile.

The team also recorded patient demographics, risk factors, clinical features, and outcomes, with fever defined as a temperature of at least 101 °F.

Overall, there were 555 of 4004 patients in the database who underwent C difficile testing, 2.5% (n = 99) of which were positive for CDI. Of the patients positive for C difficile infections, 6.5% (n = 26) had an aneurysmal subarachnoid hemorrhage, 2.9% (n = 21) had a intracerebral hemorrhage, and 1.8% (n = 52) had an ischemic stroke.

Trends Found

However, the investigators did not identify differences in demographics, severity [ICH score, National Institutes for Health Stroke Scale (NIHSS), Hunt Hess (HH), Glasgow coma scale (GCS)], mechanical ventilation, neurosurgical procedures, stress ulcer prophylaxis, or antibiotic use.

The team did find that both steroid use (P = 0.0273) and the male sex (P = 0.0112) were association with a positive C difficile test.

There were also trends found for the day of diagnosis, where 61% of patients with CDI had white blood cell counts less than 12 and 71% were afebrile.

Also, length of hospital stay, discharge disposition, mortality, and 3-month and 12-month modified Rankin were not impacted by C difficile testing results. In addition, 2 patients with C difficile infections required bowel resection.

“CDI incidence following stroke was low and most common with SAH. Male sex and steroid use were associated with a positive result,” the authors wrote. “Leukocytosis and fever occurred in under half of infected patients. Outcome measures were not impacted by CDI.”

Best Practices for CDI

By implementing best practice advisory (BPA) principals, clinicians can help reduce the occurrence of recurrent clostridium difficile infections (CDI).

Recently, a team, led by Tiffany Wu, PharmD, Department of Pharmacy, Henry Ford Hospital, determined the impact of clinical decision support on guideline-concordant C difficile infection treatments.

In the quasi-experimental study, the investigators examined patients at more than 50 primary, specialty, and urgent-care clinics. Patients included in the analysis were diagnosed with and treated for a first episode of symptomatic C difficile infection at an ambulatory clinic between November 1, 2019 and November 30, 2020.

There was a total of 189 patients included in the study, 92 prior to the best practice advisory and 97 after the best practice advisory.

In addition, 30% of the patients included in the study had CDI-related comorbidities, 35% had healthcare exposure, 65% had antibiotic exposure, and 44% had gastric acid suppression therapy within 90 days of their CDI diagnosis.

Best practice advisory was accepted 23 times out of 26 and was used to optimize therapy in 16 patients within 6 months.

Guideline-concordant therapy increased following the implementation of the best practice advisory (72% vs. 91%; P = .001).

CDI recurrence also decreased, where just 7% of the best practice advisory group had an infection recurrence within 14-56 days of the initial episode. This was compared to 27% of the non-BPA group (P <.001).

The study, “Clostridium difficile Infection Does Not Impact Outcomes in Stroke Patients,” was published online in The Neurologist.