Pardi, Ryan

Background: The incidence of Clostridioides difficile infection (CDI) in peripartum women is rising, but limited data on its effect on maternal and neonatal outcomes are available. Objective: To study the effect of peripartum CDI on pregnancy and neonatal outcomes. Design: Retrospective cohort study. Methods: Patients with peripartum CDI 12 weeks before pregnancy through 6 weeks postpartum (January 1996–February 2018) were matched with controls (peripartum women without CDI) 1:1 by age, year of delivery, and prior pregnancies. McNemar’s test and conditional logistic regression were used to analyze the effect of CDI on pregnancy and neonatal outcomes (complications, mode of delivery). p < 0.05 was considered statistically significant. Results: Overall, 101 cases and 100 controls (1997–2018) were included; median age 27 (range, 20–41) years. Timing of CDI was as follows: pre-pregnancy: 15.8% ( n = 16), during pregnancy: 51.5% ( n = 52), and postpartum: 32.7% ( n = 33). The commonest risk factor was outpatient/emergency room visits. Pregnancy and neonatal outcomes were analyzed for 67 matched pairs with CDI before or during pregnancy. Cases had higher odds of cesarean delivery ( p = 0.02) and lower odds of Group B Streptococcus (GBS) infection/colonization ( p = 0.03). Odds of cesarean delivery remained high after controlling for labor arrest disorders [odds ratio (OR): 17.23 (95% confidence interval (CI), 2.19–543.19; p = 0.004)]; odds of GBS remained low after controlling for antibiotic use (OR: 0.25, 95% CI, 0.04–0.99; p = 0.049). Neonatal outcomes were similar in cases and controls. CDI treatment did not affect treatment-related or delivery outcomes. Conclusion: Peripartum CDI was associated with higher odds of cesarean delivery and lower odds of GBS infections. Larger studies exploring the effect of CDI on pregnancy and neonatal outcomes are needed.

Background: Polymerase chain reaction (PCR) is a sensitive test for diagnosing Clostridioides difficile infection (CDI) and could remain positive following resolution of CDI. The kinetics of PCR positivity following antibiotics for CDI is unknown. We studied this and whether it predicted CDI recurrence. Methods: Adults with CDI from October 2009 to May 2017 were included. Serial stool samples within 60 days of treatment were collected. Recurrent CDI was defined as diarrhea after interim symptom resolution with positive stool PCR within 56 or 90 days of treatment completion. Contingency table analysis was used to assess the risk of recurrence. Results: Fifty patients were included [median age: 51 (range = 20–86) years, 66% women]. Treatment given was metronidazole, 50% (25); vancomycin, 44% (22); both, 4% (2); and fidaxomicin, 2% (1). Median duration of treatment for all 50 patients was 14 (range = 8–60) days. The median duration of treatment in patients who got prolonged therapy (>14 days) ( n = 10) was 47 (range = 18–60) days. Median time to negative PCR was 9 (95% CI, 7–14) days from treatment initiation, which did not differ by antibiotics given ( p = 0.5). A positive PCR during or after treatment was associated with a higher risk of recurrence at 56 days ( p = 0.02) and at 90 days ( p = 0.009). Conclusion: The median time to negative PCR in CDI was 9 days from treatment initiation. The PCR positivity during or after treatment may be useful for recurrence prediction; larger studies are needed to validate these results.

Background: The incidence of Clostridioides difficile infection (CDI) is increasing in the general population. Data on the epidemiology of CDI in peripartum women – a highly vulnerable patient population – is scarce. The objective of this study was to report the incidence of CDI in peripartum women. Methods: A single-center retrospective cohort study was conducted in peripartum women from 1997 to 2017. Peripartum CDI was defined as definite CDI (watery diarrhea for >24 h with positive stool assay) during pregnancy, or within 6 weeks postpartum. Incidence was reported per 100,000 pregnancies and time trends in incidence were analyzed using Poisson regression. Analyses were done separately for time trends before and after 2007, when CDI testing strategy changed to polymerase chain reaction. Results: From 1997 to 2017, 80 patients with peripartum CDI (47 during pregnancy, 33 postpartum) out of 125,683 pregnancies (0.064%) were identified. Incidence of CDI increased 3.4 fold (95% confidence interval 1.5–7.4, p = 0.005) over the 21 year period. Time trends were evident after ( p = 0.054), but not before 2007 ( p = 0.97). Conclusion: Incidence of CDI in peripartum women increased over the 21 year study period. The rise in incidence is concerning, and calls for heightened surveillance for CDI in this highly vulnerable population.

Abstract Background Fecal microbiota transplantation (FMT) cures ~90% of patients with recurrent Clostridioides difficile infection (rCDI). Ongoing or repeated exposure to risk factors, especially antibiotics (a modifiable risk factor but often necessary), may lead to future CDI. However, it is not known if FMT provides durable protection against future CDI despite subsequent antibiotic exposure. We studied the long-term durability of FMT against antibiotic exposure post-FMT. Methods A retrospective cohort study of patients undergoing FMT via colonoscopy for rCDI from Sep 2012 - Jun 2018 was performed. Patients were followed up for 1 year after FMT; data regarding future CDI episodes (watery diarrhea with positive stool test after interim symptom resolution), healthcare exposure, systemic non-CDI antibiotics and acid blocker therapy were collected. Primary outcome was ‘durability’ of response to FMT (defined as no CDI within 1 year post-FMT). Descriptive statistics, Chi square test, Wilcoxon test and multivariate logistic regression were used as appropriate. Results The study included 460 patients; median age 57 years (range 18–94 years), 65.2% (300) female. Overall 31.6% (144) received antibiotics; median number of courses of antibiotics, 2 (range 1–7). Of those who received antibiotics, the incidence of future CDI was 24.3% (n = 34), compared with 9% (n = 28) of those who did not receive antibiotics (P < .001). Median time to first CDI episode post-FMT was 103 (range 5–338) days. Incremental antibiotic courses did not lead to increased risk of future CDI (comparing 1, 2 or ≥3 courses, p = .68). In patients with antibiotic exposure, age and risk factors were similar in patients with and without future CDI (Table 1). Amongst those without antibiotic exposure, inflammatory bowel disease (IBD) predicted future CDI (p = .02). After controlling for risk factors and comorbidities, antibiotic use (p = .004) and IBD (p = .02) independently increased risk of future CDI. Conclusion The majority of patients with rCDI have a durable response to FMT despite ongoing risk factors. These data suggest that three-fourth of patients who receive antibiotics after FMT do not develop future CDI. IBD and antibiotic exposure independently increase the risk of future CDI. Disclosures All authors: No reported disclosures.

INTRODUCTION: Currently, surgery is the primary treatment option for refractory, severe-complicated Clostridioides difficile infection (CDI) in the inpatient setting. There are limited series reporting the efficacy of Fecal Microbiota Transplantation (FMT) to treat such cases as an alternative to surgery or in patients who are not surgical candidates. We aimed to assess the response rate and prognosis of these patients after inpatient FMT. METHODS: We conducted a retrospective chart review of patients with CDI (watery diarrhea with positive stool assay) admitted in the ICU, and who received FMT from January 2013 to July 2016. Potential cases were identified by diagnosis codes and eligibility was confirmed through manual chart review. Severe-complicated CDI was defined as CDI with any of the following: ICU admission, hypotension, shock, sepsis, megacolon, colectomy or death due to CDI. CDI was termed refractory in the absence of clinical response to antibiotics after 5 days. Recurrence was defined as typical CDI symptoms and positive stool assay within 56 days of treatment with interim symptom resolution. The primary outcome was resolution of CDI (clinical cure with no recurrence). Secondary outcomes included risk of recurrent CDI and mortality. Microsoft Excel was used for descriptive statistical analysis. RESULTS: Of 273 patients screened, 6 cases met inclusion criteria. Five patients received FMT via colonoscopy, one via retention enema. The mean age at time of FMT was 72 (range, 54-88) years, 4 (66%) patients were female. All had severe-complicated CDI, 3 had concomitant diverticulosis and none had inflammatory bowel disease (IBD). The median follow-up after FMT was 8.5 (range, 1-18) months. Three patients received non-CDI antibiotics within 6 months post-FMT, 3 received acid suppression therapy (Table 1). FMT was performed after a median of 3 (range, 1-5) episodes of CDI with a median of 4.5 previous courses of antibiotics (range 2-6 courses) (Table 1). Four of the six patients (66%) had resolution of CDI, 2 patients had recurrence. One patient died due to sepsis secondary to CDI; 3 died due to unrelated causes. CONCLUSION: In this small retrospective study, inpatient FMT was effective for treating refractory severe-complicated CDI. There was one CDI-related mortality by the end of follow up. FMT may be an alternative therapy in patients with severe-complicated CDI.