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ORLANDO – Patients on kidney dialysis who are infected with Clostridium difficile appeared to have a greater risk of infection relapse and also appeared to have a higher all-cause mortality that patients who do not have kidney disease, researchers said here.
Mortality related to C. difficile infection was 3.8% among the 104 patients with end-stage renal disease (ESRD) and 1.46% among 300 controls without ESRD, said Massini Merzkani, MD, resident in internal medicine at the Albert Einstein School of Medicine's Jacobi Medical Center in Bronx, N.Y. (No data as to significance were presented.)
Action Points
- Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
- In this retrospective study, ESRD patients with on hemodialysis C. diff infection appeared to have higher relapse rates and mortality compated to non-ESRD patients.
In his poster presentation at the National Kidney Foundation 2013 Spring Clinical Meetings, Merzkani told ľֱ that the relapse rate in severe C. difficile infection was 34.7% in the controls and 45.2% in the patients with ESRD. (No data as to significance were presented.)
"End-stage renal disease patients on dialysis with C. difficile infection have higher relapse rates which are associated with higher all-cause mortality," he said at his poster presentation.
"Treatment with combination therapy of metronidazole, vancomycin oral and rectal, or in tapered doses of vancomycin alone over 2 months, demonstrated better outcomes in these patients," Merzkani said. Metronidazole and vancomycin standard monotherapy were associated with increased relapse rates, he said.
Some of the excess relapse might have been due to the high incidence of diabetes among the ESRD patients, he suggested. "We did not correlate outcomes in this study with diabetes status. About 30% of the patients with end-stage renal disease in our study were diabetic, however. Of course, diabetes patients who are treated for other infections with antibiotics may become more vulnerable for C. difficile infection as well."
The researchers reviewed outcomes of 104 dialysis patients with ESRD who were admitted to Jacobi Medical Center from August 2002 though August 2012. They were compared with patients without chronic kidney disease who were admitted with C. difficile infection during the same time period. The researchers calculated that randomly selecting 300 of the 2,400 control patients would produce a valid comparison of outcomes.
Relapse of C. difficile infection was defined as a recurrence of symptoms within 2 months of standard successful treatment.
"Diabetes predisposed patients to more infections and they are more likely to be treated with antibiotics," commented Tamim Naber, MD, a nephrologist at the MedAmerica Group in Ventnor, N.J.
"Dialysis patients also receive more antibiotics for infections," he told ľֱ. "The combination of the two conditions can result in use of a lot of antibiotic use and these patients can build up resistance to these drugs which, in turn, makes them more susceptible to C. difficile infections."
Merzkani said that prospective studies are needed to determine "the optimal treatment in this challenging patient population."
He also said that defining C. difficile by severe or nonsevere infection as suggested by the Infectious Diseases Society of America 2010 guidelines was not helpful. The relapse rate for nonsevere cases was greater than 20%; for severe cases it was about 30%. "For end-stage renal disease patients, even nonsevere C. difficile infection should be considered severe infection," Merzkani said.
Disclosures
Merzkani had no disclosures. Naber had no disclosures.
Primary Source
National Kidney Foundation
Source Reference: Merzkani M, et al "Relapse of Clostriium Difficile associated with end stage renal disease" NKF 2013.