Background

Kidney transplant recipients (KTRs) are at increased risk of Clostridium difficile infection (CDI). We aimed to retrospectively describe the epidemiology of CDI in a national kidney transplant center over an eight-year period (where approximately 750 KTRs receive follow up).

Methods

European Center for Disease Prevention and Control case definitions for CDI case type, origin and onset were used. All adult KTRs (incident and prevalent) with diarrhoea and a positive laboratory test for Clostridium difficile were identified. Individual healthcare records, laboratory results and infection prevention surveillance records were reviewed. C. difficile positive faeces samples were referred for polymerase chain reaction (PCR) ribotyping.

Results

Between January 2008 and September 2015, 46 CDI cases (43 new and three recurrent) were diagnosed in 37 KTRs (29 kidney-only, eight pancreas-kidney). The median patient age was 51.4 years (range; 26 – 77 years) and median time between transplantation and CDI was five years (range; 1 week – 21 years).

Five cases (11%) were categorized as community-associated (CA-CDI); four were managed in the outpatient setting. The remaining 41 cases (89%) were healthcare-associated (HCA-CDI); two cases met definition criteria for severe CDI. Antimicrobial exposure in the previous three months, predominantly to the β-lactam-β-lactamase inhibitor combination drugs, was evident in 42 cases (91%).

The majority was treated with oral metronidazole and had resolution of diarrhoea within one week. Fifteen cases of HA-CDI met the Acute Kidney Injury Network (AKIN) criteria for acute kidney injury and two required critical care admission. Two patients died in the setting of HA-CDI (both of whom had multiple other comorbidities).

A total of 34 cases (74%) were successfully PCR ribotyped. 27 ribotypes were identified; ribotype 078 (three cases) and 014/020 (four cases) were seen most frequently. The identified ribotypes reflected those seen in the overall patient population during this time period.

Conclusions

Much of the available literature regarding CDI in KTRs concentrates on the first year post-transplantation. Our data suggest that CDI occurs at all time points post transplantation, with significant associated morbidity. Prudent use of antimicrobials, meticulous infection surveillance and root cause analysis remains of critical importance in this patient cohort.

CITATION INFORMATION: Kennedy C, Waldron C, Scally M, Burns K, Magee C, Fitzpatrick F. The Epidemiology of Clostridium difficile Infection in a National Kidney Transplant Center. Am J Transplant. 2016;16 (suppl 3).

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