title: [Immunosuppressive treatment as a risk factor for the occurrence of clostridium difficile infection (CDI)].
abstract: BACKGROUND
  Toxigenic Clostridium difficile strains are known as the most common infectious cause of antibiotic-associated intestinal disease and nosocomial diarrhoea. The increased incidence of hypervirulent strains gives rise to worldwide concern. In particular, courses with multiple recurrences are observed in the presence of immunosuppression.
  
  
  METHODS
  In this retrospective controlled observational study we aimed to determine immunosuppression as an independent risk factor for symptomatic CDI and to identify characteristics and differences of immunocompromised patients with respect to disease severity, disease progression, intestinal manifestations, recurrence rates and other factors. We compared symptoms and clinical features of 55 immunosuppressed patients with confirmed CDI with those of 50 patients without immunosuppressive medication (mean age 59.3 years ± 16.2 vs. 69.2 years ± 15.0) who were treated at the Departments of Internal Medicine I and IV of the University Hospital Halle (Saale), Germany, between 2006 and 2009. Multivariate analysis using binary logistic regression was performed for a control group of 105 patients without CDI. In this group, there were 62 patients without evidence of immunosuppression and 43 immunosuppressed patients (mean age 66.9 years ± 12.4 vs. 56.0 years ± 13.7).
  
  
  RESULTS
  The clinical courses of the two groups differed considerably. Immunosuppressed patients were significantly more frequently colonised with Clostridium difficile without clinically detectable manifestation or only mild clinical symptoms not requiring therapy (22 vs. 2 %, p = 0.003), while there were similar numbers of moderate (46 vs. 52 %, p = 0.503) but less severe CDI cases (27 vs. 40 %, p = 0.167). Relapses were observed more frequently in the group of immunosuppressed patients (15 vs. 6 %, p = 0.153). Multivariate analysis using logistic regression identified immunosuppression as an independent risk factor for CDI (OR = 2.75), in addition to prior antibiotic therapy (OR = 10.15) and PPI intake (OR = 2.93).
  
  
  CONCLUSIONS
  We conclude that immunosuppression has to be regarded as an independent risk factor for CDI. Immunosuppressive treatment increases the risk of colonisation and infection with Clostridium difficile and leads to a higher relapse rate in patients with CDI.
authors.affiliation: Klinik für Innere Medizin I, Universitätsklinikum Halle, Halle (Saale).
authors.forename: C
authors.initials: C
authors.lastname: Lübbert
authors.forename: C
authors.initials: C
authors.lastname: Johann
authors.forename: A S
authors.initials: AS
authors.lastname: Kekulé
authors.forename: D
authors.initials: D
authors.lastname: Worlitzsch
authors.forename: S
authors.initials: S
authors.lastname: Weis
authors.forename: J
authors.initials: J
authors.lastname: Mössner
authors.forename: S
authors.initials: S
authors.lastname: Behl
authors.forename: T
authors.initials: T
authors.lastname: Seufferlein
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016360:Clostridioides difficile; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology* / Q000276:immunology*; D004761:Enterocolitis, Pseudomembranous / Q000453:epidemiology* / Q000276:immunology* / Q000517:prevention & control; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D016867:Immunocompromised Host / Q000276:immunology*; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000276:immunology*; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D007166:Immunosuppressive Agents