C Difficile Rates Increasing in Solid Organ Transplant Recipients

Seyed M. Hosseini-Moghaddam, MD, MSc, MPH

New data show patients who receive a solid organ transplant (SOT) are at an increased risk of clostridium difficile infections (CDI), which is associated with an increased mortality rate and other complications.

A team, led by Seyed M. Hosseini-Moghaddam, MD, MSc, MPH, Multiorgan Transplant Program, University Health Network, University of Toronto, identified the incidence and outcomes for C difficile infections in patients who receive a solid organ transplant.

The Risk

It is widely known that solid organ transplant recipients are at an increased risk for CDI infections and other complications. For example, the rate of colectomy in this patient population is more than 3 times higher than the rate of post-CDI colectomy in the general population.

In the population-based cohort, the investigators examined administrative health care data in Ontario on patients who received organ allografts between April 1, 2003 and December 31,2017, following patient outcomes until March 31, 2020. There were 10,724 solid organ transplantation recipients included in the final analysis, 64.4% (n = 6901) of which were men.

The median age of the patient population was 54 years.

The investigators sought a primary outcome of hospital admission with CDI diagnosis. They also looked at secondary outcomes of all-cause death, intensive care unit admission, acute kidney injuries (AKI) that require dialysis, and fulminant CDI comprising of toxic megacolon, ileus, perforation, or colectomy.

The team also evaluated the association between short- and long-term mortality, defined as death occurring within or after 90 days following CDI. Finally, they evaluated several variables, including age, sex, Deyo-Charlson Comorbidity Index, solid organ transplantation type, early- or late-onset CDI, fulminant CDI, intensive care unit admission, and acute kidney injury requiring acute dialysis.

The most common type of solid organ transplantation was kidney transplants, which occurred in 60.2% (n = 6453) of the study participants. The median follow-up period was 5.0 years, resulting in 61m987 person-years of follow-up. There was also 726 patients (6.8%) included who were hospitalized with CDI.

Increased Mortality

Overall, the 1-year CDI incidence increased throughout the duration of the study (from 23.1; 95% CI, 12.8-41.8 per 1000 person-years in 2004 to 46.7; 95% CI, 35.0-62.3 per 1000 person-years in 2017; P = .001).

C difficile infections was linked to a 16.8% (n = 122) 90-day mortality rate.

Specifically for the kidney transplant cohort, CDI was generally late-onset (median interval, 2.2; IQR, 0.4-6.0 years) compared with recipients of other organs.

In addition, AKI that required dialysis was significantly linked to short-term (aOR, 1.86; 95% CI, 1.07-3.26) and long-term (aHR, 1.89; 95% CI, 1.29-2.78) mortality.

Late-onset CDI was also significantly associated with a greater risk of both short-term (aOR, 4.26; 95% CI, 2.51-7.22) and long-term (aHR, 2.49; 95% CI, 1.78-3.49) mortality.

“In this study, increasing CDI trends in annual cohorts of SOT recipients were observed,” the authors wrote. “Posttransplant CDI was associated with mortality, and late-onset CDI was associated with a greater risk of death than early-onset CDI.”

Changes Needed

The investigators do hope the trial results force real world clinical changes for solid organ transplant recipients.

“These findings suggest that preventive strategies should not be limited to the initial months following transplantation,” the authors wrote. “Comprehensive therapeutic approaches targeting acute kidney injury risk factors in SOT recipients may reduce short- and long-term post-CDI mortality.”

The study, “Incidence and Outcomes Associated With Clostridioides difficile Infection in Solid Organ Transplant Recipients,” was published online in JAMA Network Open.