Intestinal infections due to Clostridium difficile (i.e., C. difficile) are rising nationally, and data here suggest that the dialysis patient population is not immune to this trend. The characteristic gastroenteritis associated with C. difficileinfection is caused by a toxin produced by the bacterium. The clinical consequences can be severe, and include persistent diarrhea and acute weight loss. Treatment can be challenging. Antibiotics commonly used to treat C. difficileinfection include metronidazole and oral vancomycin; more recently, the U.S. Food and Drug Administration approved fidaxomicin, a first-in-class macrolide antibiotic. Despite treatment, up to 20 percent of patients suffer a recurrence, often iatrogenic in nature, when the recurrence is due to the use of other antibiotics that allow colonized C. difficile to expand in the gastrointestinal tract.
Rates of hospitalization for intestinal infection with C. difficile roughly doubled during the study era among both incident and prevalent dialysis patients. Regional variation in admission rates is substantial, with the lowest rates observed in the East South Central and West South Central areas and the highest in the New England and East North Central divisions. Among incident dialysis patients, admission rates during the first six months of dialysis increased markedly between 2003 and 2010. The timing of such high rates is important, as many dialysis patients are malnourished at the initiation of chronic dialysis, due to poor appetite that accompanies worsening uremia prior to initiating dialysis. Among prevalent dialysis patients, there is some evidence of seasonality, which might reflect increased use of oral antibiotics for respiratory infection during the winter season.
All of these trends, along with trends of hospitalization for infection with antibiotic-resistant bacteria, should be watched closely, as the increase in C. difficile infection is underappreciated, with many patients simply receiving outpatient treatment. In the future we will assess oral antibiotic treatment patterns, the antibiotic profiles that precede C. difficile hospitalizations, and the duration of antibiotic treatments. We will also assess regional and facility-level variation in the use of proton pump inhibitors, which are widely used in the dialysis patient population and likely increase the risk of C. difficile infection by altering the chemistry of the gut.