COVID-19 Measures Reduce Risk of C Diff Infections

Jessica Allegretti, MD

The increase in hospitalized patients has many worried about an additional increase in Clostridium difficile (C diff) infections (CDI).

A team, led by Jessica R. Allegretti, Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, evaluated the prevalence, patient characteristics, and clinical outcomes of CDI among hospitalized patients with COVID‐19.

COVID-19 and CDI

Gastrointestinal symptoms has been a hallmark of COVID-19 since the beginning of the pandemic, with about a third of patients suffering from diarrhea.

While the US Food and Drug Administration (FDA) has yet to approve a treatment for COVID-19, hospitalized patients often are treated with broad-spectrum antibiotics, which is escalated as the clinical status of the patients deteriorates.

However, this class of treatment has been associated with an increased risk of CDI, even as hospitals take measures to limit the person-to-person spread of the virus.

“Strict isolation and social‐distancing protocols adopted by hospitals since the start of the pandemic may help mitigate this risk,” the authors wrote.

The Patients

In the retrospective cohort study, the investigators examined hospitalized COVID-19 patients from 9 hospitals in Massachusetts.

Each patient in the cohort underwent stool testing for C diff infections and were confirmed to be positive with COVID-19 from a nasopharyngeal swab polymerase chain reaction (PCR) test, and testing was performed via glutamate dehydrogenase (GDH) and enzyme‐linked immunosorbent assay (ELISA) immunoassay (EIA) for toxin and considered diagnostic if both tests were positive.

The researchers compared outcomes and mortality for hospitalized COVID-19 patients with and without CDI. All CDI patients were exposed to at least 2 (2-8) antibiotics prior to their CDI diagnosis.

The researchers performed student's t‐test and Fisher's exact tests for continuous variables and categorical variables, respectively, on univariate analyses.

Test Results and Analysis

Overall, there were 97 (24.9%) patients who were tested for CDI, with a mean age of 62.4 years old. Of this group, 5 (5.2%) patients tested positive for CDI, which was lower than the overall inpatient CDI-positive rate in 2019 (n = 280; 9.8% of tests performed). However, this was not statistically significant (P = 0.16).

GDH/EIA‐positive rates were similar between the COVID‐19 and historical cohort (5.2% vs 5.3%).

In addition, the PCR positive rate among GDH/EIA‐indeterminant patients was significantly lower among COVID‐19 patients (n = 0; 0% vs n = 121; 42%; P = 0.02).

“In comparison, rates of confirmed CDI were lower among patients hospitalized with COVID‐19,” the authors wrote. “This difference was entirely driven by patients who were PCR positive but GDH/EIA indeterminant as the rates of GDH/EIA positivity were similar between COVID‐19 and the historical cohorts. This may suggest lower rates of C. difficile colonization despite a similar risk of CDI.”

However, the findings do show that COVID-19 patients who receive at least 2 systemic antibiotics are at a significant risk of developing CDI.

On the other hand, some of the measures taken up because of COVID-19 do show the importance of hand hygiene, contact precautions, and appropriate isolation of patients in lowering hospital‐acquired CDI.

“In conclusion, the prevalence of CDI among hospitalized COVID‐19 patients was not higher despite widespread use of multiple antibiotics, likely due to aggressive contact precaution and isolation measures implemented for COVID‐19,” the authors wrote. “The development of CDI was associated with poor outcomes and a high mortality rate among hospitalized COVID‐19 patients. A low threshold for early CDI testing should be implemented among COVID‐19 patients to ensure prompt diagnosis and appropriate therapeutic intervention.”

The study, “Prevalence and impact of Clostridioides difficile infection among hospitalized patients with coronavirus disease 2019,” was published online in the Journal of Gastroenterology and Hepatology.