Clostridium Difficile Infection Among Hematopoietic Stem Cell Transplant Recipients and Subsequent Development of Graft-Versus-Host Disease
Notice bibliographique
Résumé
Introduction: Clostridium difficile (C. difficile) is an anaerobic gram positive rod that colonizes 20-40 % of hospitalized patients and the most common cause of antibiotic-associated diarrhea. The clinical manifestations of C. difficile infection (CDI) range from asymptomatic carriage to severe fulminant infection, leading to bowel perforation and death. Stem cell transplantation (SCT) recipients are at risk of CDI due to prolonged neutropenia, use of broad-spectrum antibiotics, mucosal damage and changes in intestinal microbiota induced by cytotoxic chemotherapy, microbial co-infection and possibly graft-versus-host disease (GVHD). The incidence of CDI amongst patients undergoing autologous SCT varies between five and 15 % and among those undergoing allogenic SCT 12 and 34% in literature1-5. Some studies have found a strong association between CDI and GVHD, gut GVHD and/or severe GVHD1-4 but this was not universally demonstrated5. Many studies looking at CDI in the SCT setting are limited by the ubiquity of traditional risk factors for CDI and small sample sizes. Methods: In this retrospective observational study, we aimed to review the epidemiology and clinical management of CDI in our autologous and allogeneic SCT recipients and subsequent clinical outcomes including development of GVHD. All recipients of autologous and allogeneic SCT at Vancouver General Hospital over the 10-year period between January 1, 2008 and December 31, 2017, who had diarrhoea and at least one positive stool test for C. difficile toxin by polymerase chain reaction were eligible for inclusion. Patient demographics, transplant details including GVHD prophylaxis, treatment for CDI, complications from CDI and subsequent development of acute and chronic GVHD and survival outcomes were collected by means of review of their electronic and written clinical records. An ethics approval was obtained from the hospital ethics committee. Results: Out of the 2104 patients who underwent SCT during the study period, 277 (13.2%) had at least one episode of C. difficile positive diarrhea. The incidence was higher among recipients of allogeneic SCT (19.6%) compared to autologous SCT recipients (9.6%). The majority of the patients (86.7%) were treated with oral metronidazole as a first line therapy and 18.9% required a second line treatment, with oral vancomycin in most cases, due to persistent symptoms with toxin positivity. 21% had recurrence of CDI after an initial successful treatment and 9.4% had two or more recurrences. There was no death directly attributable to acute CDI and the rate of major complications was low. Two patients required an intensive care unit admission with fulminant CDI and one patient underwent bowel resection. 57% of allogeneic SCT patients with post-transplant CDI subsequently developed acute GVHD (45.8% grade 2 or higher acute GVHD, 34% gut GVHD). 60.6% developed chronic GVHD (46.9% moderate to severe GVHD, 19.2% gut chronic GVHD). The median progression free survival was 670.5 days (range 1-3938) and the overall survival time was 984.5 days (range 10-3938). The commonest cause of death was malignancy relapse. Conclusion: The incidence of CDI among autologous and allogeneic SCT recipients in British Columbia was 9.6% and 19.6% respectively. There was no death immediately attributable to CDI and few patients developed fulminant CDI. Of the SCT patients who had CDI, 57% and 60.6% subsequently developed acute and chronic GVHD respectively. References: Trifilio SM et al . Changing epidemiology of Clostridium difficile-associated disease during stem cell transplantation. Biol Blood Marrow Transplant. 2013;19: 405-409.Chakrabarti et al.Clostridium difficile infection in allogeneic stem cell recipients is associated with severe graft-versus-host disease and non-relapse mortality. Bone Marrow Transplant. 2000; 26(8):871-6.Alonso CD et al. Epidemiology and outcomes of Clostridium difficile infections in hematopoietic stem cell transplant recipients. Clinical Infectious Diseases. 2012;54(8):1053-63.Dubberke ER et al. Clostridium difficile-associated disease in allogeneic hematopoietic stem cell transplant recipients: risk associations, protective associations, and outcomes. Clin Transplant. 2010;24(2):192-198.Kinnebrew MA et al. Early Clostridium difficile infection during allogeneic hematopoietic stem cell transplantation. Plos ONE 2014; 9(3):e90158. Disclosures No relevant conflicts of interest to declare.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,001 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,001 | 0,002 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,001 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,002 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».