Retrospective Comparative Study Between Primary-Infection and Relapse of Clostridium difficile Disease

Abstract

Introduction: Clostridium difficile infection has worryingly increased in incidence, severity and relapse rates.
Methods: An 18-month retrospective analysis was carried
out based on the clinical records of patients with confirmed
infection hospitalized in Beatriz Ângelo Hospital, Portugal.
Subjects were divided into two groups: ‘primary-infection’
and ‘relapse’. The following clinical characteristics were assessed: age, gender, community versus hospital acquired
infection, previous antibiotic therapy, proton-pump inhibitors use, severity criteria (namely, > 65 years, leukocytes >
20 000/uL and creatinine > 1.5 above baseline), antibiotics
used, duration of antibiotic therapy, hospital length-of- stay
and mortality.
Results: Overall severity was higher in primary-infections
(leukocytes > 20 000/uL 21.3% vs 12.0%, creatinine> 1.5
from baseline 38.3% vs 20.8%), as were patient’s mortality
rates (23.4% vs 4.0%). Although vancomycin is recommended – in monotherapy or in association with metronidazole – in
severe disease, our study showed that in patients with primary-infection plus 2 or 3 severity criteria, metronidazole alone
was the most frequent choice (46.2% if 2 criteria present and
57.1% if 3 criteria present). In recurrent infections vancomycin was the initial choice even in less severe cases (100.0%
if no criteria and 68.8% if 1 criteria present). Proton-pump
inhibitors use was higher in relapses (84.0% vs 65.2%).
Conclusion: This study suggests that primary-infections
comprise greater clinical severity and mortality; emphasizes
the importance of a severity scoring system to assure appropriate antibiotic regimens and supports the idea that proton-pump inhibitors might be a risk factor.