P1173 - Clostridioides difficile Recurrence Is Highest Following Concomitant Antimicrobial Administration Within 30 Days of Treatment

Monday, October 25, 2021

10:30 AM – 4:15 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Abdelkader Chaar, MD

Yale-New Haven Hospital
New Haven, CT, United States

Abdelkader Chaar, MD¹, John Damianos, MD², Rabia Rizwan, MD¹, Muhammad Sohail Mansoor, MD³, Prabin Sharma, MD⁴, Umer Ejaz Malik, MD⁵, Houssam Alnahhas, MD, MPH⁶, Paul Feuerstadt, MD⁷
¹Yale-New Haven Hospital, New Haven, CT; ²Yale University School of Medicine, New Haven, CT; ³GI Specialists of Georgia, Marietta, GA; ⁴NYU Langone Health, Mineola, NY; ⁵Albany Medical Center, Albany, NY; ⁶Syria Public Health Network, London, England, United Kingdom; ⁷Yale University School of Medicine and PACT-Gastroenterology Center, Hamden, CT

Introduction: Clostridioides difficile infection (CDI) is an epidemic in the United States. The strongest risk factor for initial infection and subsequent recurrence is antibiotic (ABX) usage for non-CDI indications. Patients who get CDI frequently require concomitant ABX at the same time as treatment of CDI or shortly thereafter. Our study was designed to consider recurrence of CDI (rCDI) in patients receiving concomitant ABX at the same time as treatment of CDI or shortly thereafter.

Methods: We retrospectively reviewed medical records for patients who had their first symptomatic CDI while admitted to Yale-New Haven Hospital in 2013 and 2014. Data collected included demographics, diagnostics and non-CDI ABX during and/or 30 days after completing CDI treatment. Patients were grouped into those who didn’t receive concomitant ABX (CDITx-cABX), those receiving ABX for other indications than CDI at the same time as treatment of CDI (CDITx+cABX) and those receiving ABX for other indications within 30-days of completion of CDI therapy regardless of any use during treatment (CDITx+cABX30). Our primary outcome was recurrence within 14-90 days; other outcomes included ICU stay, 30-day colectomy, and readmission. We performed logistic regression to calculate the odds of recurrence depending on the timing of exposure.

Results: 418 patients had CDI (mean age: 65.7 years, 52.6% female). 260 (62.2%) were exposed to non-CDI ABX. 37.8% were CDITx-cABX, 36.6% were CDITx+cABX while 25.6% were CDITx+cABX30. Recurrence rates were 4.4%, 7.1% and 16.8%, for CDITx-cABX, CDITx+cABX and CDITx+cABX30, respectively. There was no significant increased risk of rCDI with CDITx+cABX but there was with CDITx+cABX30 [OR 5.18 (1.7-15.65), p= 0.004]. Patients with CDITx+cABX30 were at greater risk of 90-day rCDI (p< 0.05), ICU at diagnosis (p< 0.05), ICU within 30-days (p< 0.05), 30- (p< 0.001) and 90-day readmission (p< 0.001) compared with no concomitant ABX exposure.

Discussion: Our study found a high rate of utilization of non-CDI ABX during or shortly after completing CDI treatment. Non-CDI ABX use within 30 days following the treatment of CDI is associated with a 5.18-fold increase in the odds of developing rCDI within 90 days. Concomitant ABX within the “window of vulnerability” likely further worsens dysbiosis leading to remarkable increases in recurrence. Careful consideration should be made for ABX indication, type and duration in patients being treated for CDI or shortly after treatment.

	N=418	Recurrence within 14-90 days n (%)	Odds ratio for recurrent CDI within 14-90 days (95% CI)
	N=418	Recurrence within 14-90 days n (%)	Unadjusted	Adjusted ^@
No concomitant ABX (CDITx-cABX)	158 (37.8%)	7 (4.4%)	1 (reference)	1 (reference)
Non-CDI ABX only at the same time as treatment of CDI (CDITx+cABX)	153 (36.6%)	11 (7.1%)	1.67 (0.63-4.42)	1.62 (0.5-5.4)
Non-CDI ABX within 30-days of completion of CDI therapy regardless of any use during treatment (CDITx+cABX30)	107 (25.6%)	18 (16.8%)	4.36 (1.75-10.85)	5.18 (1.7-15.65)
	N=418	CDITx-cABX (n=158)	CDITx+cABX (n=153)	CDITx+cABX30 (n=107)
14–90-day recurrence, n (%)	55 (13.2%)	7 (4.4%)	11 (7.2%)	18 (16.8%) ^*
Days to recurrence, mean ± SD	28.4 ± 21	29.25 ± 24	33.5 ± 23	25 ± 17
ICU at the time of diagnosis, n (%)	127 (30.4%)	35 (22.2%)	53 (34.6%) ^#	39 (36.4%) ^*
ICU transfer within 30 days, n (%) ^$	17/291 (5.8%)	4/123 (3.3%)	4/100 (4%)	9/68 (13.2%) ^*
30-day colectomy, n (%)	3 (0.7%)	0/157 (0%)	2 (1.3%)	1 (0.9%)
30-day re-admission, n (%)	127 (30.4%)	36 (22.8%)	29 (19%)	62 (59.9%) ^&
90-day re-admission, n (%)	193 (46.2%)	64 (40.5%)	57 (37.3%)	72 (67.3%) ^&

Table: Table 1: Outcomes in Different Groups Depending on the Timing of Exposure to Antibiotics.

@ Adjusted for age, Charlson score, recent hospitalization within 12 weeks and ICU transfer within 30 days of diagnosis.
# p < 0.05 when comparing “CDITx+cABX” to “CDITx-cABX”.
* p < 0.05 when comparing “CDITx+cABX30” to “CDITx-cABX”.
& p < 0.001 when comparing “CDITx+cABX30” to “CDITx-cABX”.
$ This group does not include those who were already admitted to ICU at the time of diagnosis (Nf291).

Disclosures:
Abdelkader Chaar indicated no relevant financial relationships.
John Damianos indicated no relevant financial relationships.
Rabia Rizwan indicated no relevant financial relationships.
Muhammad Sohail Mansoor indicated no relevant financial relationships.
Prabin Sharma indicated no relevant financial relationships.
Umer Ejaz Malik indicated no relevant financial relationships.
Houssam Alnahhas indicated no relevant financial relationships.
Paul Feuerstadt: Ferring/Rebiotix – Advisory Committee/Board Member, Consultant, Speaker's Bureau. Merck and Co. – Speaker's Bureau. SERES Therapeutics – Advisory Committee/Board Member.

Abdelkader Chaar, MD¹, John Damianos, MD², Rabia Rizwan, MD¹, Muhammad Sohail Mansoor, MD³, Prabin Sharma, MD⁴, Umer Ejaz Malik, MD⁵, Houssam Alnahhas, MD, MPH⁶, Paul Feuerstadt, MD⁷. P1173 - Clostridioides difficile Recurrence Is Highest Following Concomitant Antimicrobial Administration Within 30 Days of Treatment, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.