Clostridioides difficile Infection Associated With Increased Short-Term Mortality After Solid Organ Transplant

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Investigators assessed the incidence and outcomes of post-transplant Clostridioides difficile infection in patients receiving solid organ transplants.

Post-transplant Clostridioides difficile infection (CDI) in solid organ transplant (SOT) recipients is associated with a 90-day mortality incidence of about 17%, researchers reported in JAMA Network Open.

The findings are based on a 15-year, population-based cohort study of health care data in Ontario, Canada. Eligible participants were all adults who received an SOT in Ontario from April 1, 2003, to December 31, 2017; Patients were followed up until March 31, 2020. The primary outcome was hospital admission with a diagnosis of CDI according to International Classification of Diseases, 10th Revision.

A total of 10,724 patients were included (mean age, 52.33 [SD, 12.94] years; 6901 [64.4%] men). The most common SOT was kidney transplant (6453; 60.2%). The median follow-up was 5.0 (IQR, 2.3-8.8) years, or 61,987 person-years of follow-up.

The study authors identified 726 CDI hospitalizations (6.8%), with 275 early-onset cases (37.9%) occurring within 90 days of transplantation and 451 late-onset cases (62.1%) occurring after 90 days. Overall, the CDI incidence rate was 11.7 (95% CI, 10.9-12.6) per 1000 person-years. The highest incidence rate occurred in patients with multiorgan transplant (45.3 per 1000 person-years; 95% CI, 23.6-87.1 per 1000 person-years).

The incidence rate increased from 34.0 per 1000 person-years (95% CI, 22.2-52.1 per 1000 person-years) in 2010 to 68.2 per 1000 person-years (95% CI, 50.9-91.4 per 1000 person-years) in 2011 and remained elevated afterward.

The 90-day mortality rate for patients with CDI was 16.8% (122 of 726). Patients with lung transplants had the highest short-term mortality rates vs recipients of other SOTs with CDI (21 of 93 [22.6%] vs 101 of 633 [15.9%], respectively; P =.11). A significant risk for mortality was associated with acute kidney injury that required dialysis (adjusted odds ratio [aOR], 1.86; 95% CI, 1.07-3.26).

Late-onset CDI was associated with a significantly higher short-term mortality compared with early-onset CDI (97 of 451 [21.5%] vs 25 of 275 [9.1%]; P =.001). Late-onset CDI also was associated with higher odds of 90-day mortality after hospitalization for CDI (aOR, 4.26; 95% CI, 2.51-7.22) and with a relatively greater risk for longer-term death after CDI (adjusted hazard ratio, 2.49; 95% CI, 1.78-3.49).

The researchers noted that they did not have access to information on immunosuppressive regimens and antibiotic therapies at an individual level and outcomes of interest did not include mild CDI cases managed in outpatient settings. Additionally, the cohort was limited to transplant centers in Ontario, which may affect the generalizability of the results.

“The findings of this large cohort of organ transplant recipients suggest a trend toward increasing risk of CDI over time,” stated the investigators. “Acute kidney injury preventive measures, such as adequate fluid repletion, avoidance of hypotension in critically ill SOT recipients, readjustment of nephrotoxic medications based on drug levels, and close kidney function monitoring, should be considered in the management of CDI.”

Disclosure: One of the study authors declared an affiliation with a pharmaceutical company. Please see the original reference for a full list of authors’ disclosures.


Hosseini-Moghaddam SM, Luo B, Bota SE, et al. Incidence and outcomes associated with Clostridioides difficile infection in solid organ transplant recipients. JAMA Netw Open. 2021;4(12):e2141089. doi: 10.1001/jamanetworkopen.2021.41089