P2216 - Concomitant Cephalosporins or Vancomycin During or After Treatment of Clostridioides difficile Infection Increases Risk of 3-Month CDI Recurrence

John Damianos, MD¹, Abdelkader Chaar, MD², Rabia Rizwan, MD³, Muhammad Sohail Mansoor, MD⁴, Prabin Sharma, MD⁵, Umer Ejaz Malik, MD⁶, Houssam Alnahhas, MD, MPH⁷, Paul Feuerstadt, MD^8
1Yale University School of Medicine, New Haven, CT; ²Yale-New Haven Hospital, New Haven, CT; ³Yale New Haven Hospital, New Haven, CT; ⁴GI Specialists of Georgia, Marietta, GA; ⁵NYU Langone Long Island, Mineola, NY; ⁶Albany Medical Center, Albany, NY; ⁷Syria Public Health Network, London, England, United Kingdom; ⁸Yale University School of Medicine and PACT-Gastroenterology Center, Hamden, CT

Introduction: Exposure to antibiotics (ABX) is an important risk factor for Clostridioides difficile infection (CDI). Most patients treated for CDI receive ABX for non-CDI infections during and immediately following treatment of CDI. In this study, we aimed to identify which classes of ABX are most commonly associated with recurrence when used during and/or after CDI treatment.

Methods: We performed a retrospective analysis of all adult patients ( > 18 years) admitted to Yale-New Haven Hospital in 2013-2014 who were diagnosed with CDI. For each patient, non-CDI treatment related ABX were recorded during therapy and/or up to 30-days following completion. Patients were stratified into 2 groups: Those who received concomitant non-CDI antibiotics and those who did not. The cohorts were compared for demographics, comorbidities, recent surgeries/hospitalizations, labs, and outcomes (e.g., 90-day recurrence, colectomy, and readmission).

Results: 418 cases of CDI were identified; 198 (47.4%) were males with a mean age of 65.7 ± 16.8 years. Recurrence was seen in 55 patients overall (13.2%). When comparing those exposed to ABX with those who were not, there were no statistically significant differences among the medical co-morbidities, but those receiving ABX did have a higher frequency of glucocorticoid use within 2 weeks prior CDI (60.8% vs 19.6%, p< 0.001). Patients receiving ABX were more likely to be intubated (22.3% vs 13.3%, p=0.02) and were more likely to require tube feeds (23.5% vs 10.8%, p=0.001). Of the CDI cases, 260 (62.2%) were exposed to at least one non-CDI ABX during or up to 30-days following treatment. The most commonly used ABX classes were penicillins (33.5%), cephalosporins (26.6%), and fluoroquinolones (25.4%). Cephalosporins (13.5% vs 6.8%, p=0.046) and intravenous vancomycin (16.2% vs 6.1%, p=0.002) appeared to be more frequently associated with recurrence within 90 days (Table 1).

Discussion: Use of cephalosporins and intravenous vancomycin during or within 30-days of treatment for CDI is associated with a higher frequency of recurrence than no concomitant ABX. Additional consideration regarding ABX stewardship and selection should be given to patients treated or recently treated for CDI requiring ABX for other infections. Future research should investigate interventions which could mitigate the risk of recurrence when patients require these therapies as well as consider the potential cumulative effect of multiple ABX on recurrence.

Antimicrobial	Subjects exposed* (N, (% of 418))	Recurrence (%) with Concomitant ABX Exposure	Recurrence (%) without Concomitant ABX Exposure	p value
Penicillins	140 (33.5%)	17/140 (12.1%)	19/278 (6.8%)	0.095
Cephalosporins	111 (26.6%)	15/111 (13.5%)	21/307 (6.8%)	0.046
Fluoroquinolones	106 (25.4%)	12/106 (11.3%)	24/312 (7.7%)	0.315
Vancomycin	105 (25.1%)	17/105 (16.2%)	19/313 (6.1%)	0.002
Tetracyclines	29 (6.9%)	5/29 (17.2%)	31/389 (8%)	0.092
Sulfonamides	24 (5.7%)	1/26 (4.2%)	35/394 (8.9%)	0.710
Carbapenem	9 (2.2%)	2/9 (22.2%)	34/409 (8.3%)	0.177
Fosfomycin	8 (1.9%)	2/8 (25%)	34/410 (8.3%)	0.145
Aminoglycosides	7 (1.7%)	2/7 (28.6%)	34/411 (8.3%)	0.115
Nitrofurantoin	6 (1.4%)	0/6 (0%)	36/412 (8.7%)	1
Daptomycin	4 (1%)	0/4 (0%)	36/414 (8.7%)	1
Macrolides	4 (1%)	0/4 (0%)	36/414 (8.7%)	1
Clindamycin	3 (0.7%)	0/3 (0%)	36/415 (8.7%)	1

Table: Table 1: Classes of ABX Prescribed to Patients During or Up To 30 Days After CDI Treatment and their Risk of Recurrence.

* Patients could have received more than 1 ABX and therefore the number of exposures does not equal the number of patients.


Disclosures:
John Damianos indicated no relevant financial relationships.
Abdelkader Chaar 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 Pharmaceuticals – Advisory Committee/Board Member, Consultant, Speaker's Bureau. Merck and Co – Speaker's Bureau. SERES Therapeutics – Advisory Committee/Board Member.


John Damianos, MD¹, Abdelkader Chaar, MD², Rabia Rizwan, MD³, Muhammad Sohail Mansoor, MD⁴, Prabin Sharma, MD⁵, Umer Ejaz Malik, MD⁶, Houssam Alnahhas, MD, MPH⁷, Paul Feuerstadt, MD⁸. P2216 - Concomitant Cephalosporins or Vancomycin During or After Treatment of Clostridioides difficile Infection Increases Risk of 3-Month CDI Recurrence, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.