Surprising Added Risk for Clostridium difficile in Elderly Patients

John Haran, MD, Department of Emergency Medicine, Associate Clinical Director of the Center for Microbiome Research, University of Massachusetts Medical School

John Haran, MD

The use of acid reducing medication can cause recurrent Clostridium difficile (C. difficile) infection in elderly patients, according to a November report.

Researchers from the University of Massachusetts Medical School retrospectively examined the electronic medical records of 616 patients with C. difficile in order to determine whether the risk of recurrent infection differed among living environments. The patients, who were all aged 65 years or older, were infected between 2012—2014. The researchers sorted them by their living environment.

The study authors wrote that recurrent C. difficile infection increased almost 200% between 2001—2012, with patients remaining most vulnerable for reinfection in the months or years following their first infections. Recurrent infection can occur in up to nearly a quarter of patients.

Of the 616 total patients, 26% experienced recurrent C. difficile infection within the first year. Recurrent infection reached 24% among community dwelling patients and was 28% among elderly patients residing in nursing homes, the researchers reported.

The investigators found no differences in the demographic information from the patients, or the medical histories between patients who contracted and did not contract recurrent infection. There did appear to be a greater prevalence of prior 6 month history of C. difficile infection treatment in those with recurrent infection. Within 6 months of their initial treatment, patients were likely to have been exposed to an acid reducing medication or antibiotic.

There did not seem to be a difference between the groups of patients based on living environment according to factors of age, sex, race, or previous history of C. difficile infection. Their rates of exposure to antibiotics, acid reducing medications, or corticosteroids did not differ either.

The researchers found higher levels of exposure to antibiotics in elderly community dwelling adults with recurrent C. difficile infection than in those without, as well as in the nursing home environment. Along the same lines, elderly patients with recurrent infection had greater exposure to acid reducing medicines than those without recurrent infection in the community and nursing homes. Looking at corticosteroids, the researchers learned that adults in the community with recurrent infection had similar exposure to those without the recurrent infection. But in the nursing home, residents with recurrent infection had a higher level of corticosteroid exposure than those without the recurrent infection, something study author John Haran, MD, called surprising.

“The most surprising findings from this study was how corticosteroid exposure among nursing home elders increased the risk of recurrent C. difficile infection while among community-dwelling elders it lowered the risk,” he told MD Magazine. “This finding adds a dimension of living environment to the controversy over corticosteroids and risk of recurrent C. difficile, where it has been shown to both increase and reduce the risk of disease.”

These findings are consistent with the existing literature, the study authors commented, but also noted that elderly adults in nursing homes were only slightly more likely, and not statistically significantly, more likely to have recurrent C. difficile infection.

Many recommendations suggest reexamining the use of antibiotics, and the study authors said similarly that it’s important to reassess what medications patients are on to reduce extraneous ones.

“Seeing how in our study, and multiple previous reports in the literature, acid reducing medications have been shown to increase the risk of C. difficile infection, we feel it is important to readdress what medication a patient is on and try and reduce unnecessary medications,” Dr. Haran concluded. “Especially to reduce use of acid reducing medications (such as PPIs or H2 blockers) that increase risk of disease. Similarly with antibiotic use — trying to reduce unnecessary antibiotic use may be key to reducing complications from a C. difficile infection.”

The report, titled “Medication Exposure and Risk of Recurrent Clostridium difficile Infection in Community-Dwelling Older People and Nursing Home Residents,” was published in the Journal of the American Geriatrics Society.