Retrospective Cohort Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Aug 27, 2021; 13(8): 926-938
Published online Aug 27, 2021. doi: 10.4254/wjh.v13.i8.926
Clostridioides difficile infection in liver cirrhosis patients: A population-based study in United States
Syeda Sahra, Mohammad Abureesh, Shivantha Amarnath, Motasem Alkhayyat, Rawan Badran, Abdullah Jahangir, Vivek Gumaste
Syeda Sahra, Mohammad Abureesh, Shivantha Amarnath, Rawan Badran, Abdullah Jahangir, Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10305, United States
Motasem Alkhayyat, Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Vivek Gumaste, Department of Gastroenterology, Staten Island University Hospital, Staten Island, NY 10305, United States
Author contributions: Sahra S, Jahangir A, and Badran R contributed to writing the manuscript; Data extraction and results were drawn by Abureesh M, and Alkhayyat M. Proof reading and supervision was done by Alkhayyat M, Amarnath S, and Gumaste V.
Institutional review board statement: Study protocol was reviewed with Research Department. It was deemed as a population-based study with no patient identifiers and did not need IRB approval.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All authors report no conflicts of interests (personal or financial).
Data sharing statement: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request
STROBE statement: The authors have read the STROBE Statement, and the manuscript was prepared and revised according to the STROBE Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Syeda Sahra, MD, Doctor, Department of Internal Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States. ssahra@northwell.edu
Received: May 8, 2021
Peer-review started: May 8, 2021
First decision: June 7, 2021
Revised: June 11, 2021
Accepted: July 22, 2021
Article in press: July 22, 2021
Published online: August 27, 2021
Abstract
BACKGROUND

Clostridioides (formerly Clostridium) difficile infection (CDI) is an increasingly frequent cause of morbidity and mortality in hospitalized patients. Multiple risk factors are documented in the literature that includes, but are not limited to, antibiotics use, advanced age, and gastric acid suppression. Several epidemiological studies have reported an increased incidence of CDI in advanced liver disease patients. Some have also demonstrated a higher prevalence of nosocomial infections in cirrhotic patients.

AIM

To use a large nationwide database, we sought to determine CDI’s risk among liver cirrhosis patients in the United States.

METHODS

We queried a commercial database (Explorys IncTM, Cleveland, OH, United States), and obtained an aggregate of electronic health record data from 26 major integrated United States healthcare systems comprising 360 hospitals in the United States from 2018 to 2021. Diagnoses were organized into the Systematized Nomenclature of Medicine Clinical Terms (SNOMED–CT) hierarchy. Statistical analysis for the multivariable model was performed using Statistical Package for Social Sciences (SPSS version 25, IBM CorpTM). For all analyses, a two-sided P value of < 0.05 was considered statistically significant.

RESULTS

There were a total of 19387760 patients in the database who were above 20 years of age between the years 2018-2021. Of those, 133400 were diagnosed with liver cirrhosis. The prevalence of CDI amongst the liver cirrhosis population was 134.93 per 100.000 vs 19.06 per 100.000 in non-cirrhotic patients (P < 0.0001). The multivariate analysis model uncovered that cirrhotic patients were more likely to develop CDI (OR: 1.857; 95%CI: 1.665-2.113, P < 0.0001) compared to those without any prior history of liver cirrhosis.

CONCLUSION

In this large database study, we uncovered that cirrhotic patients have a significantly higher CDI prevalence than those without cirrhosis. Liver cirrhosis may be an independent risk factor for CDI. Further prospective studies are needed to clarify this possible risk association that may lead to the implementation of screening methods in this high-risk population.

Keywords: Clostridioides difficile, Chronic liver disease, Liver cirrhosis, Liver transplant

Core Tip: Clostridium difficile infections (CDI) are a leading cause of hospital morbidity and mortality. The risk factors for CDI in liver cirrhosis patients are studied in the national data base. CDIs in liver transplantation is a life-threatening situation as these patients are malnourished and immunocompromised. Therefore, special emphasis was given to the cohort with history of liver transplantation and relevant literature was reviewed.