SAN DIEGO (FRONTLINE MEDICAL NEWS) – Nearly one in ten adults hospitalized with candidemia had Clostridium difficile coinfections in a large multistate study.

Be vigilant – look for candidemia and Clostridium difficile infection occurring together,” Sharon Tsay, MD, said at an annual scientific meeting on infectious diseases. “In patients with CDI, one in 100 developed candidemia, but in patients with candidemia, nearly one in 10 had CDI,” she said. Patients with diabetes, hemodialysis, solid organ transplantation, or a prior recent hospital stay were significantly more likely to have a CDI coinfection even after the researchers controlled for potential confounders, she reported.

Both candidemia and CDI are serious health care–associated infections that disproportionately affect older, severely ill, and immunosuppressed patients, noted Dr. Tsay, an Epidemic Intelligence Service officer in the mycotic diseases branch at the Centers for Disease Control and Prevention, Atlanta. Every year in the United States, about 50,000 individuals are hospitalized with candidemia, and about 30% die within 30 days of diagnosis. The prevalence of CDI is about tenfold higher, and 30-day mortality rates range between about 1% and 9%.

To understand why candidemia and CDI occur together, consider the effects of oral vancomycin therapy, Dr. Tsay said. Antibiotic pressure disrupts normal gut flora, leading to decreased immunity and Candida colonization. Disrupting the gut microbiome also increases the risk of CDI, which can damage gut mucosa, especially in hypervirulent cases such as C. difficile ribotype 027. Vancomycin can also directly damage the gut mucosa, after which Candida can translocate into the bloodstream.

To better characterize CDI and candidemia coinfections in the United States, Dr. Tsay and her associates analyzed data from CDC’s Emerging Infections Program , which tracks infections of high public health significance in 10 states across the country. Among 2,129 patients with a positive blood culture for Candida from 2014 through 2016, 193 (9%) had a diagnosis of CDI within 90 days. Two-thirds of CDI cases preceded candidemia (median, 10 days) and one-third occurred afterward (median, 7 days). Rates of 30-day mortality rates were 25% in patients with and without CDI. For both groups, Candida albicans was the most commonly identified species, followed by C. glabrata and C. parapsilosis.

Demographics were generally similar between candidemic patients with and without CDI. “Underlying conditions were quite common, and patients with diabetes and solid organ transplant had greater odds of CDI coinfection,” Dr. Tsay said. Diabetes and solid organ transplant were significant risk factors for CDI in univariate analyses, while liver and inflammatory bowel diseases, malignancy, pancreatitis, and HIV infection were not. Among health care risk factors, significant predictors of coinfection included hemodialysis, prior hospital stay, and central venous catheter placement.

A multivariate model identified four risk factors for CDI in patients with candidemia – solid organ transplantation (odds ratio, 3.0), hemodialysis (OR, 1.8), prior hospital stay (OR, 1.7), and diabetes (OR, 1.4). Data were limited to case report forms and did not include information about CDI severity or treatment, Dr. Tsay said.

Dr. Tsay and her associates reported having no conflicts of interest.


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