Study identifies potential predictors of hospital-onset C. difficile infection

In patients colonized with Clostridioides difficile, risk factors for infection included longer length of stay, exposure to multiple classes of antibiotics, use of opioids, and cirrhosis, whereas use of laxatives was associated with a lower risk.


Longer length of stay, exposure to multiple classes of antibiotics, use of opioids, and cirrhosis may help predict progression to Clostridioides difficile infection during hospitalization in colonized patients, a retrospective study found.

Researchers assessed a cohort of colonized patients identified through a systematic C. difficile screening program at an academic tertiary hospital in Canada. Overall, 513 of 960 patients who screened positive on admission between November 2013 and January 2017 were included in the study. Exclusion criteria included history of C. difficile infection, presence of diarrhea or other severe gastrointestinal symptoms on admission, short hospital stay, and palliative care admission. Results of the industry-supported study were published online on July 9 by Clinical Infectious Diseases.

A total of 39 (7.6%) patients developed hospital-onset C. difficile infection, with a 30-day attributable mortality of 15%. The factors independently associated with an increased risk of hospital-onset C. difficile infection were longer length of stay (adjusted odds ratio [OR] per day, 1.03; P=0.006), exposure to multiple classes of antibiotics (adjusted OR per class, 1.45; P=0.02), use of opioids (adjusted OR, 2.78; P=0.007), and cirrhosis (adjusted OR, 5.49; P=0.008). The antimicrobials that correlated with the greatest risk of hospital-onset C. difficile infection were beta-lactams with beta-lactamase inhibitors (OR, 3.65; P<0.001), first-generation cephalosporins (OR, 2.38; P=0.03), and carbapenems (OR, 2.44; P=0.03).

On the other hand, use of laxatives was associated with a lower risk of C. difficile infection (adjusted OR, 0.36; P=0.01). This finding contrasts with those of other studies that had suggested use of laxatives was associated with increased occurrence of C. difficile infection in the general population. “We hypothesize that laxatives could increase the risk of colonization by decreasing resistance to colonization, but not of progression to [C. difficile infection] once colonization has occurred,” the study authors said.

Patient age and use of proton-pump inhibitors were not significant predictors of hospital-onset C. difficile infection. Also, primary prophylaxis against C. difficile with oral vancomycin or oral or IV metronidazole was not a significant predictor, although the study had limited power to detect a difference in the incidence of C. difficile infection among these patients.

Limitations of the study include a lack of information on patients' immune status and the use of single-step screening by polymerase chain reaction, rather than the currently recommended two-step detection method, the authors noted. They added that due to the single-center design, results may not be generalizable to other health care settings.