Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI.
Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI.
Am J Health Syst Pharm. 2019 Apr 17;76(9):581-590. doi: 10.1093/ajhp/zxz032.
The greatest challenge in treating Clostridioides difficile infection (CDI) is disease recurrence, which occurs in about 20% of patients, usually within 30 days of treatment cessation. We sought to identify independent predictors of first recurrence among a national cohort of veterans with CDI.
We conducted a case-control study among acute and long-term care Veterans Affairs (VA) inpatients and outpatients with a first CDI episode (positive stool sample for C. difficile toxin[s] and receipt of at least 2 days of CDI treatment) between 2010 and 2014. Cases experienced first recurrence within 30 days from the end of treatment. Controls were those without first recurrence matched 4:1 to cases on year, facility, and severity. Multivariable conditional logistic regression was used to identify predictors of first recurrence.
We identified 32 predictors of first recurrence among 974 cases and 3,896 matched controls. Significant predictors included medication use prior to (probiotics, fluoroquinolones, laxatives, third- or fourth-generation cephalosporins), during (first- or second-generation cephalosporins, penicillin/amoxicillin/ampicillin, third- and fourth-generation cephalosporins), and after CDI treatment (probiotics, any antibiotic, proton pump inhibitors [PPIs], and immunosuppressants). Other predictors included current biliary tract disease, malaise/fatigue, cellulitis/abscess, solid organ cancer, medical history of HIV, multiple myeloma, abdominal pain, and ulcerative colitis.
In a large national cohort of outpatient and acute and long-term care inpatients, treatment with certain antibiotics, PPIs, immunosuppressants, and underlying disease were among the most important risk factors for first CDI recurrence.
治疗艰难梭菌感染（CDI）最大的挑战是疾病复发，约 20%的患者会在治疗停止后 30 天内出现复发。我们试图确定 CDI 退伍军人国家队列中首次复发的独立预测因素。
我们对 2010 年至 2014 年间首次发生 CDI 发作（粪便样本中存在艰难梭菌毒素 [s] 且接受至少 2 天 CDI 治疗）的急性和长期护理退伍军人事务部（VA）住院和门诊患者进行了病例对照研究。病例组在治疗结束后 30 天内首次复发。对照组是那些在没有首次复发的情况下，按年份、设施和严重程度 4:1 匹配的病例。多变量条件逻辑回归用于确定首次复发的预测因素。
我们在 974 例病例和 3896 例匹配对照中确定了 32 个首次复发的预测因素。显著的预测因素包括治疗前（益生菌、氟喹诺酮类、泻药、第三代或第四代头孢菌素）、治疗期间（第一代或第二代头孢菌素、青霉素/阿莫西林/氨苄西林、第三代和第四代头孢菌素）和治疗后（益生菌、任何抗生素、质子泵抑制剂 [PPI] 和免疫抑制剂）使用的药物。其他预测因素包括当前胆道疾病、不适/疲劳、蜂窝织炎/脓肿、实体器官癌、HIV 病史、多发性骨髓瘤、腹痛和溃疡性结肠炎。
在一个大型的全国门诊和急性及长期护理住院患者队列中，某些抗生素、PPI、免疫抑制剂和基础疾病的治疗是 CDI 首次复发的最重要的危险因素之一。
