Clostridium difficile infection (CDI) is often encountered in the solid-organ transplant patient population. The incidence in kidney transplant recipients ranges between 3.5-16%. There are CDI risk factors that are more prevalent in the transplant population, such as the use of gastric acid suppressing agents. All kidney recipients at our institution will utilize either a histamine-2 receptor antagonist (H2RA) or proton pump inhibitor (PPI) to help minimize gastrointestinal (GI) side effects of immunosuppressants. This study was conducted to describe CDI post-kidney transplant and compare CDI rates between acid suppressing classes.

This was a retrospective cohort study of adult kidney recipients transplanted between January 1, 2009 and June 30, 2013. Subjects receiving per-protocol immunosuppression with a follow-up of 12 months were included. Those receiving multi-organ transplants and having rejection or death prior to initial discharge were excluded. Two cohorts were defined based upon acid suppressing class prescribed at discharge from transplant. All recipients continue or initiate H2RA therapy unless using a PPI prior to transplant, in which case PPI use is maintained. Univariate analysis was performed to compare the rates of CDI between acid suppressing classes.

Of 728 recipients screened, 522 were included: 339 subjects used an H2RA and 183 continued PPI use. Overall, the 12-month post-transplant incidence of CDI was 4% (21/522). Basiliximab was the most commonly used induction agent (17/21, 81%) followed by anti-thymocyte globulin, rabbit (4/21, 19%). The median time from transplant to CDI was 48 days (IQR: 15-87 days). Over half (12/21, 57%) had antimicrobial exposure 30 days prior to CDI. Only three of 21 subjects had a rejection episode during the 12-month follow-up; one episode was prior to CDI, one after CDI, and the other subject experienced CDI and rejection concurrently. The CDI cases were classified as healthcare facility-onset, healthcare facility-associated (n=6), community-associated (n=3), and community-onset, healthcare facility associated (n=12). Five subjects experienced multiple CDI episodes. There was a significantly higher incidence of CDI with PPI use (12/183, 6.6%) compared to H2RA use (9/339, 2.6%), P=0.03. Given the observed increased incidence of CDI in the PPI group, an H2RA may be favored for GI protection over a PPI.

CITATION INFORMATION: Spinner M, Patel K, Neuner E, Stephany B. Increased Incidence of Clostridium difficile Infections with Proton Pump Inhibitor Use Post-Kidney Transplant. Am J Transplant. 2016;16 (suppl 3).

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