783 - Clostridioides difficile Infection among Maintenance Hemodialysis Patients

Background: Patients on maintenance hemodialysis (MHD) are 2-2.5 times more likely to develop Clostridioides difficile infection (CDI) with mortality rates 2-fold higher compared to the general population. The goal of this study was to determine factors and outcomes associated with severe/fulminant CDI among MHD patients.

Methods: A retrospective cohort study was performed among MHD patients admitted to 2 tertiary care hospitals, with first episodes of CDI between January 2015 and December 2018. MHD patients who had CDI at admission were identified through Theradoc® and confirmed by electronic medical records review. Using the Infectious Diseases Society of America criteria, non-severe CDI was defined as a white blood cell count ≤ 15000 cells/mL and severe/fulminant CDI was defined as a white blood cell count of ≥ 15000 cells/mL, hypotension, shock, megacolon and/or ileus. Creatinine values were not included. Patient demographics, comorbidities, antimicrobial exposure and 60-day mortality were collected on all patients.

Results: A total of 103 MHD patients with CDI were identified during the study period, of whom 68 (66%) had non-severe CDI and 35 (34%) had severe/fulminant CDI. The average age at admission was 65.3 years, 48.5% were female, and 59.2% were Caucasian. The average albumin level was 3.1 g/dL, and the average Charlson comorbidity index was 6.8. On univariate analyses, risk factors associated with severe/fulminant CDI as compared to non-severe CDI were older age at admission, elevated white blood cell count, exposure to extended-spectrum penicillins in the previous 90 days, and 60-day mortality after the first CDI (p-value ≤0.05). On multivariable logistic regression analysis, three factors remained significantly associated with severe/fulminant CDI (adjusted odds ratio [aOR], 95% confidence interval): 1] age ≥65 years (aOR=6.3 [2.25-17.45]), 2] extended-spectrum penicillins (aOR=2.7 [1.05-6.85], and 3] 60-day mortality after the first CDI (aOR=3.6 [1.11-11.74]).

Conclusion: A substantial proportion of patients requiring MHD with CDI present with severe/fulminant disease and are at increased risk of death. Reducing exposure to extended-spectrum penicillins may prevent severe/fulminant CDI in this patient population.