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Clostridium difficile Infection in Hospitalized Cirrhotic Patients with Hepatic Encephalopathy

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Oana Cristina Stoica1,2, Carol Stanciu2, Camelia Cojocariu1,2, Egidia Miftode1,3, Lucian Boiculese1, Anca Trifan1,2, Irina Girleanu1,2

1) Gr. T. Popa University of Medicine and Pharmacy; 2) St. Spiridon Emergency Hospital, Institute of Gastroenterology and Hepatology;
3) Hospital of Infectious Diseases, Iasi, Romania

DOI: http://dx.doi.org/10.15403/jgld.2014.1121.244.csd

Background & Aims:
Patients with liver cirrhosis are at-risk population for Clostridium difficile infection (CDI). There is a paucity of data on the incidence of CDI in cirrhotics with hepatic encephalopathy (HE). The aim of the study was to evaluate the incidence and risk factors for CDI in cirrhotics hospitalized with HE.

Methods: A retrospective analysis of all cirrhotics with HE admitted at a tertiary referral center from January 2012 to December 2014 was made. Patients’ medical charts were reviewed, and demographics, laboratory parameters, antibiotics use, etiology of cirrhosis, and therapy of HE, as well as the results of stool samples for toxins A and B (enzyme immunoassay) were carefully searched. The presence of toxin A or B (or both) in stool samples was defined as CDI. Data on cirrhotics with HE and CDI (study group) were compared with those from patients without CDI (control group).

Results: A total of 231 cirrhotic patients were hospitalized with HE mostly stage 2 and 3, and 17 (7.3%) of them were diagnosed with CDI. The overall CDI incidence rate was 57.2 cases per 10,000 patient-days. As compared with control patients, those with HE and CDI were more likely to have older age, increased serum creatinine level, hepatorenal syndrome (HRS), and more prior hospitalizations. On multivariate analysis, antibiotic therapy, age over 65 years, and HRS remained significantly related with the development of CDI.

Conclusion: Hospitalized cirrhotics with HE are at risk for developing CDI, and clinicians treating such patients should be aware of this infection as rapid detection and prompt treatment may improve outcomes.

Key words: risk factors – liver cirrhosis – incidence – Clostridium difficile – hepatic encephalopathy.
Abbreviations: CDI: Clostridium difficile infection; CI: confidence interval; EIA: enzyme immunoassay; HE: hepatic encephalopathy; HRS: hepatorenal syndrome; MELD: Model for End-Stage Liver Disease; OR: odds ratio; PPIs: proton pump inhibitors; SBP: spontaneous bacterial peritonitis.