title: Clostridium difficile infection after allogeneic hematopoietic stem cell transplant: strain diversity and outcomes associated with NAP1/027.
abstract: Allogeneic hematopoietic stem cell transplantation (HSCT) recipients are at high risk for developing Clostridium difficile infection (CDI). We studied the incidence, risk factors, NAP1/027 prevalence, and clinical outcomes, including acute lower gastrointestinal graft-versus-host disease (GI GVHD), associated with early CDI in this population. A retrospective review was conducted of patients who underwent allogeneic HSCT at Memorial Sloan Kettering Cancer Center from January 1, 2005 to September 30, 2010. Early CDI was defined as infection occurring from day -10 to day +40 from stem cell infusion. Among 793 patients who received allogeneic HSCTs, early CDI occurred in 11.9%; 56% cases were between day -5 and day +5. Overall incidence was 25.2 cases/10,000 at-risk days. There was a high prevalence of NAP1/027 strains during peak incidence (61% in 2008). NAP1/027 was the most common strain in both adult and pediatric cases (24% and 23%, respectively). CDI was clinically mild, including those due to NAP1/027. Metronidazole was the primary treatment for 91 of 94 patients, 7 of 8 cases refractory to metronidazole had no response to vancomycin, and none was due to NAP1/027. Relapse of CDI was common (31%). The cumulative incidence of GI GVHD in patients with and without early CDI was 6.8% and 8%, respectively (P = .5). Most cases of CDI occurred during conditioning or immediately after transplant. Despite high prevalence of NAP1/027, we found only mild disease. Most patients were treated successfully with metronidazole, irrespective of NAP1/027 status. There was no significant association between early CDI and subsequent development of GI GVHD. This study demonstrates the high incidence of CDI early after allogeneic HSCT with wide diversity among infecting strains. Despite the high prevalence of NAP1/027, the disease is mild but relapses are common. No association was found between CDI and subsequent development of GI GVHD.
authors: Services of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Medical College of Cornell University, New York, New York. Electronic address: kambojm@mskcc.org.
authors: Mini
authors: M
authors: Kamboj
authors: Services of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
authors: Kun
authors: K
authors: Xiao
authors: Services of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Medical College of Cornell University, New York, New York.
authors: Anna
authors: A
authors: Kaltsas
authors: Services of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
authors: Yao-Ting
authors: YT
authors: Huang
authors: Services of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
authors: Janet
authors: J
authors: Sun
authors: Services of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
authors: Dick
authors: D
authors: Chung
authors: Department of Hematology, Queen Elizabeth Hospital, Hong Kong.
authors: Saliangi
authors: S
authors: Wu
authors: Services of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
authors: Anna
authors: A
authors: Sheahan
authors: Services of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Medical College of Cornell University, New York, New York.
authors: Kent
authors: K
authors: Sepkowitz
authors: Department of Medicine, Weill Medical College of Cornell University, New York, New York; Adult Bone Marrow Transplant, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
authors: Ann A
authors: AA
authors: Jakubowski
authors: Services of Infectious Diseases, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Medical College of Cornell University, New York, New York.
authors: Genovefa
authors: G
authors: Papanicolaou
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000890:Anti-Infective Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000187:drug effects / Q000235:genetics* / Q000302:isolation & purification; D003015:Clostridium Infections / Q000188:drug therapy* / Q000209:etiology / Q000276:immunology / Q000382:microbiology; D005260:Female; D041981:Gastrointestinal Tract / Q000276:immunology / Q000382:microbiology; D006086:Graft vs Host Disease / Q000276:immunology / Q000382:microbiology / Q000517:prevention & control*; D019337:Hematologic Neoplasms / Q000473:pathology / Q000628:therapy*; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008795:Metronidazole / Q000627:therapeutic use; D008875:Middle Aged; D019653:Myeloablative Agonists / Q000009:adverse effects; D012008:Recurrence; D012189:Retrospective Studies; D019172:Transplantation Conditioning; D014184:Transplantation, Homologous; D016896:Treatment Outcome
chemical_list: D000890:Anti-Infective Agents; D019653:Myeloablative Agonists; D008795:Metronidazole
keywords: Allogeneic hematopoietic stem cell transplantation; Clostridium difficile infection; Immunocompromised host; NAP1/027 strain