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Multiple CDI Recurrences Linked to Older Age, Hemodialysis, Nitrofurantoin Use – Renal and Urology News

Multiple recurrences of Clostridioides difficile infection (CDI) are more common among older adults, those undergoing hemodialysis, and those receiving nitrofurantoin therapy, according to study results published in Open Forum Infectious Diseases.

Researchers conducted a study to examine the epidemiology of multiple CDI recurrences among a geographically diverse population of adults in the United States. They also aimed to identify associated risk factors that are present at the time of initial CDI diagnosis. Multiple CDI recurrence was defined as 2 or more recurrent CDI episodes within 180 days of the initial diagnosis. Data for this analysis were captured from adult patients at 2 sites between January 2018 and August 2019. Multivariable logistic regression was used to identify significant risk factors, with adjustments for age, sex, race/ethnicity, comorbidities, health care and medication exposures, hospitalization, intensive care unit admission, and initial CDI treatment.

A total of 18,828 patients were included in the final analysis, of whom 48% were aged 65 years and older, 58% were women, and 65.5% were non-Hispanic White. Overall, 15,367 (81.6%) patients had no documented CDI recurrence, 2579 (13.7%) experienced a single recurrence, and 882 (4.7%) experienced multiple recurrences (range, 2-5 episodes).

Among patients who experienced multiple CDI recurrences, 79.6% had 2 recurrences, 16.6% had 3 recurrences, 3.5% had 4 recurrences, and 0.3% had 5 recurrences. The researchers noted variation in the time between each CDI recurrence (median, 43 [IQR, 27-65] days).

Further efforts to improve the identification of patients at risk of mrCDI may require novel approaches, including exploring the use of biomarkers or gut metabolites to predict CDI recurrence.

During a follow-up period of 180 days, the risk for any CDI recurrence was significantly higher among patients who were aged 65 years and older at the time of initial CDI diagnosis relative to those in other age groups (P ≤.01). Recurrent CDI risk was also higher in patients with health care-associated vs community- or hospital-onset initial CDI diagnoses (P <.01). The risk for 2 or more CDI recurrences was higher in Hispanic and non-Hispanic White patients relative to other racial/ethnip groups, as well as among those with toxin-positive vs toxin-negative initial CDI diagnoses (both P <.01).

Patients with vs without multiple CDI recurrences were more likely to have certain underlying conditions, such as chronic kidney disease (22.0% vs 14.4%; P <.0001), diverticular disease (15.6% vs 11.2%; P =.006), and hematologic malignancy or solid tumors (17.9% vs 14.1%; P =.03). They also reported higher rates of chronic hemodialysis (6.3% vs 3.0%; P =.001), previous surgical procedures (16.0% vs 12.1%; P =.02), antibiotic use (77.3% vs 67.3%; P <.001), and proton-pump inhibitor use (38.7% vs 3.0%; P =.02).

In the fully adjusted analysis, significant predictors of multiple CDI recurrences were as follows:

  • Older age (≥65 years; adjusted odds ratio [aOR], 1.91; 95% CI, 1.55-2.35);
  • Chronic hemodialysis (aOR, 2.28; 95% CI, 1.48-3.51);
  • Hospitalization (aOR, 1.64; 95% CI, 1.33-2.01); and
  • Nitrofurantoin use up to 12 weeks prior to initial diagnosis (aOR, 1.95; 95% CI, 1.18-3.23).

Limitations of this analysis include the potential overestimation of CDI recurrences, insufficient data on the association between toxin-positivity status and multiple recurrences, and the possibility that some risk factors were underestimated.

According to the researchers, “Further efforts to improve the identification of patients at risk of mrCDI [multiple recurrent CDI] may require novel approaches, including exploring the use of biomarkers or gut metabolites to predict CDI recurrence.”

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

This article originally appeared on Infectious Disease Advisor


Guh AY, Li R, Korhonen L, et al. Characteristics of patients with initial Clostridioides difficile infection (CDI) that are associated with increased risk of multiple CDI recurrences. Open Forum Infect Dis. Published online March 6, 2024. doi:10.1093/ofid/ofae127