Clostridium Difficile Infection in Patients Undergoing Hematopoietic Cell Transplantation. Results from the Transplantation Group at the Catholic University Hospital in Santiago, Chile

Introduction: Patients undergoing hematopoietic cell transplantation (HCT) have an increased risk of Clostridium difficile infection (CD) and multiple risk factors have been found. Literature reports CD infection in nearly 20% of transplanted patients. No information about this infection in HCT patients has been reported in Chile.

Patients and Methods: We performed a retrospective analysis of 250 patients undergoing HCT at the Catholic University Hospital in Santiago, Chile, between 2000 and the first semester of 2013, including allogeneic (allo) HCT and autologous (auto) HCT patients. Statistical analysis of the data was conducted using SPSS Statistics v21.

Results: Of the 250 transplanted patients studied, 59% (n=147) were allo-HCT and 41% (n=103) were auto-HCT. The mean age was 39 years old (range: 15-69), with a male predominance (151 patients; 60%). The main indication for HCT was acute leukemia (n=104; 42%) followed by multiple myeloma (n=36; 14%) and lymphoma (n=49; 20%). 93% of patients received myeloablative (MA) conditioning regimen, and all of them received proton pump inhibitors and prophylactic antibiotics during the previous months of the HCT. Of the 250 patients studied, 192 (77%) had at least one episode of diarrhea that required study, among them 13% (n=25) were documented as positive for CD (toxin assay or PCR test), the mean age of this group was 36 years old (range: 18-62), also with a male predominance (15 patients; 60%). All of the infected patients had mild to moderate diseases and there were no deaths attributed to it. 80% (n=20) of the infected patients underwent allo-HCT and 20% (n=5) auto-HCT. In the allo-HCT group, 53% had acute lymphoblastic leukemia (ALL), 6% acute myeloid leukemia (AML), 24% chronic myeloid leukemia (CML) and 12% other causes. In the auto-HCT group, 40% were transplanted due to multiple myeloma, 20% amyloidosis, 20% germinal cancer and 20% acute myeloid leukemia. No patient required total central parenteral nutrition previous to the infection. During the 3 months before HCT, 84% (n=21) of the infected patients used antibiotics including cephalosporins, carbapenem, aminoglicosides and vamcomycin. The overall incidence of CD infection in the first week, month and year after transplant, was 4.0%, 6.4% and 10%, respectively, with a median time frame from transplantation to infection diagnosis of 20 days. In auto-HCT, 7 days, 30 days and 1 year CD incidence was 1.9, 2.9 and 4.9%, respectively. In allo-HCT, 7 days, 30 days and 1 year CD incidence was 5.4, 8.8 and 13.6%, respectively. There was no significant statistical difference in overall survival (OS) between the infected and non-infected patients one year after the transplant (OS 67.6% for CD negative vs. 72.0% for CD positive, p=0.61).

Conclusions: In our institution CD infection in patients undergoing HCT had a similar incidence to other reports. Most of cases occur before the first week after HCT (40% of the cases), and the incidence of the infection remained stable during the first year after the procedure. We identified the type of transplant (allo-HCT 3 times higher risk than auto-HCT) and disease (ALL 3 times higher risk than AML) as risk factors for CD infection.