title: Clostridium Difficile Colonization in Hematopoietic Stem Cell Transplant Recipients: A Prospective Study of the Epidemiology and Outcomes Involving Toxigenic and Nontoxigenic Strains.
abstract: Clostridium difficile is a leading cause of infectious diarrhea in hematopoietic stem cell transplant (HSCT) recipients. Asymptomatic colonization of the gastrointestinal tract occurs before development of C. difficile infection (CDI). This prospective study examines the rates, risk factors, and outcomes of colonization with toxigenic and nontoxigenic strains of C. difficile in HSCT patients. This 18-month study was conducted in the HSCT unit at the Karmanos Cancer Center and Wayne State University in Detroit. Stool samples from the patients who consented for the study were taken at admission and weekly until discharge. Anaerobic culture for C. difficile and identification of toxigenic strains by PCR were performed on the stool samples. Demographic information and clinical and laboratory data were collected. Of the 150 patients included in the study, 29% were colonized with C. difficile at admission; 12% with a toxigenic strain and 17% with a nontoxigenic strain. Over a 90-day follow-up, 12 of 44 (26%) patients colonized with any C. difficile strain at admission developed CDI compared with 13 of 106 (12%) of patients not colonized (odds ratio [OR], 2.70; 95% confidence interval [95% CI], 1.11 to 6.48; P = .025). Eleven of 18 (61%) patients colonized with the toxigenic strain and 1 of 26 (4%) of those colonized with nontoxigenic strain developed CDI (OR, 39.30; 95% CI, 4.30 to 359.0; P < .001) at a median of 12 days. On univariate and multivariate analyses, none of the traditional factors associated with high risk for C. difficile colonization or CDI were found to be significant. Recurrent CDI occurred in 28% of cases. Asymptomatic colonization with C. difficile at admission was high in our HSCT population. Colonization with toxigenic C. difficile was predictive of CDI, whereas colonization with a nontoxigenic C. difficile appeared protective. These findings may have implications for infection control strategies and for novel approaches for the prevention and preemptive treatment of CDI in the HSCT patient population.
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan.
authors.forename: Tania
authors.initials: T
authors.lastname: Jain
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Christopher
authors.initials: C
authors.lastname: Croswell
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Department of Internal Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Varinia
authors.initials: V
authors.lastname: Urday-Cornejo
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Department of Internal Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Reda
authors.initials: R
authors.lastname: Awali
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Department of Internal Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Jessica
authors.initials: J
authors.lastname: Cutright
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Department of Pathology, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Hossein
authors.initials: H
authors.lastname: Salimnia
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Department of Internal Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Harsha Vardhan
authors.initials: HV
authors.lastname: Reddy Banavasi
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Alyssa
authors.initials: A
authors.lastname: Liubakka
authors.affiliation: Detroit Medical center University Laboratories, Detroit, Michigan.
authors.forename: Paul
authors.initials: P
authors.lastname: Lephart
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Karmanos Cancer Center, Detroit, Michigan; Department of Internal Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Teena
authors.initials: T
authors.lastname: Chopra
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Karmanos Cancer Center, Detroit, Michigan; Department of Internal Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Sanjay G
authors.initials: SG
authors.lastname: Revankar
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Karmanos Cancer Center, Detroit, Michigan; Department of Internal Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan.
authors.forename: Pranatharthi
authors.initials: P
authors.lastname: Chandrasekar
authors.affiliation: Wayne State University School of Medicine, Detroit, Michigan; Karmanos Cancer Center, Detroit, Michigan; Henry Ford Hospital, Detroit, Michigan; Department of Internal Medicine, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan. Electronic address: galanga1@hfhs.org.
authors.forename: George
authors.initials: G
authors.lastname: Alangaden
mesh_terms: D000328:Adult; D000368:Aged; D064591:Allografts; D016360:Clostridioides difficile / Q000235:genetics / Q000302:isolation & purification / Q000472:pathogenicity; D003967:Diarrhea / Q000209:etiology / Q000235:genetics / Q000382:microbiology; D004761:Enterocolitis, Pseudomembranous / Q000209:etiology / Q000235:genetics / Q000382:microbiology; D005260:Female; D005500:Follow-Up Studies; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies
keywords: Clostridium difficile; Hematopoietic stem cell transplantation