Is Clostridium difficile infection a risk factor for subsequent bloodstream infection?

Robert J Ulrich, Kavitha Santhosh, Jill A Mogle, Vincent B Young, Krishna Rao, Robert J Ulrich, Kavitha Santhosh, Jill A Mogle, Vincent B Young, Krishna Rao

Abstract

Background: Clostridium difficile infection (CDI) is a common nosocomial diarrheal illness increasingly associated with mortality in United States. The underlying factors and mechanisms behind the recent increases in morbidity from CDI have not been fully elucidated. Murine models suggest a mucosal barrier breakdown leads to bacterial translocation and subsequent bloodstream infection (BSI). This study tests the hypothesis that CDI is associated with subsequent BSI in humans.

Methods: We conducted a retrospective cohort study on 1132 inpatients hospitalized >72 h with available stool test results for toxigenic C. difficile. The primary outcome was BSI following CDI. Secondary outcomes included 30-day mortality, colectomy, readmission, and ICU admission. Unadjusted and adjusted logistic regression models were developed.

Results: CDI occurred in 570 of 1132 patients (50.4%). BSI occurred in 86 (7.6%) patients. Enterococcus (14%) and Klebsiella (14%) species were the most common organisms. Patients with BSI had higher comorbidity scores and were more likely to be male, on immunosuppression, critically ill, and have a central venous catheter in place. Of the patients with BSI, 36 (42%) had CDI. CDI was not associated with subsequent BSI (OR 0.69; 95% CI 0.44-1.08; P = 0.103) in unadjusted analysis. In multivariable modeling, CDI appeared protective against subsequent BSI (OR 0.57; 95% CI 0.34-0.96; P = 0.036). Interaction modeling suggests a complicated relationship among CDI, BSI, antibiotic exposure, and central venous catheter use.

Conclusions: In this cohort of inpatients that underwent testing for CDI, CDI was not a risk factor for developing subsequent BSI.

Keywords: Bloodstream infection; Central line; Clostridium difficile infection; Colitis.

Conflict of interest statement

Conflicts of Interest

All authors: no reported conflicts.

Copyright © 2017 Elsevier Ltd. All rights reserved.

Figures

Figure 1. Testing algorithm for Clostridium difficile…
Figure 1. Testing algorithm for Clostridium difficile infection
This flow diagram illustrates this University of Michigan diagnostic testing algorithm for detecting toxigenic Clostridium difficile in stool [38]. Abbreviations: CDI, Clostridium difficile infection; EIA, enzyme immunoassay; GDH, glutamate dehydrogenase; PCR, polymerase chain reaction.
Figure 2. Algorithm for determining BSI significance
Figure 2. Algorithm for determining BSI significance
This figure illustrates the decision pathway used to determine if a positive blood culture is a true subsequent BSI or a contaminant. Definitions of “suspected pathogen” and “standard criteria” are found in the methods section. Abbreviations: ID, infectious disease; CDI, Clostridium difficile infection; BSI, Bloodstream infection; CoNS, Coagulase negative Staphylococcus.
Figure 3. Microbiology of subsequent BSI
Figure 3. Microbiology of subsequent BSI
The graph shows the number of each species of BSI detected. If category is a genus, this included multiple species. Abbreviations: CoNS, Coagulase negative Staphylococci.

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