Sepsis Among Common C. Diff Complications During One-Year Follow-Up Period

Paul Feuerstadt, MD

Sepsis was a common Clostridioides difficile infection (C diff) complication throughout a 12-month follow-up period and was most commonly observed in the cohort of patients with 3 or more C diff infection recurrences, according to a paper published in SAGE Open Medicine.

Investigators from around New England conducted a retrospective analysis of more than 46,000 adult patients with C diff infection in order to evaluate the clinical complications of C diff in patients with index and recurrent cases. The investigators used the IQVIA PharMetrics Plus database to looks for patients aged 18-64 years with an index C diff episode that required inpatient stay or an outpatient visit, followed by a treatment for the infection. Treatments included vancomycin, fidaxomicin, metronidazole, rifaximin, or bezlotoxumab, or fecal microbiota transplant (FMT – though it was rare).

Each infection ended after a 14-day C diff-free period was observed, leaving recurrent C diff to be defined as further infection within an 8-week window for a period of 12 months.

A total of 3129 patients (6.7%) experienced 1 recurrence, while 1% had 2 recurrences, and 0.3% had 3 or more recurrences. The study authors also noted that autoimmune diseases, such as ulcerative colitis, Crohn’s disease, type 1 diabetes, rheumatoid arthritis and multiple sclerosis, were present in 18%, 23%, 24%, and nearly 40% of patients, respectively, in patients with 0, 1, 2, or 3 or more C diff infection recurrences.

Antibiotics were prescribed for three-quarters of all patients in all groups in the 6 months preceding the index C diff infection, the investigators found. Gastric acid-suppressing agents were prescribed in 28%, 33%, 39%, and 38%, respectively, in patients with 0, 1, 2, or 3 or more C diff infection recurrences, the study authors also noted.

Vancomycin was used to treat about a third of all index C diff infection patients, while metronidazole was used to treat a little more than half of the patients, the study authors wrote. Fidaxomicin was used to treat about 4% of patients. Vancomycin was the most commonly prescribed antibiotic used in recurrent C diff cases, with 55% of patients getting the antibiotic for the first recurrence, 56% getting it for their second recurrence, and 60% getting it for their third recurrence.

During the 12-month follow-up period, the investigators observed sepsis in 16%, 27%, 33%, and 43%, respectively, in patients with 0, 1, 2, or 3 or more C diff infection recurrences. No patient had more than 2 sepsis episodes during the 12-month follow-up period. Additionally, subtotal colectomy or diverting loop ileostomy was performed in 4%, 7%, 9%, and 10% of patients, respectively, in patients with 0, 1, 2, or 3 or more C diff infection recurrences.

“Our findings indicate that, among patients with more recurrent C diff infection, there was a parallel trend for higher rates of colectomy and sepsis,” the study authors wrote.

The study authors also said that patients with 3 or more recurrences also had the highest health care resource utilization and total, all-cause, direct medical costs of all the recurrence cohorts. Sepsis was highest among this group with the most recurrences, and the study authors hypothesized that this was due to having more opportunities to suffer from this type of adverse outcome.

“Reduction in recurrent C diff infection may be an important step to reduce the burden of serious clinical complications,” they concluded.